Provider Demographics
NPI:1902852155
Name:COYNE, MARA BETH (PA-C)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:BETH
Last Name:COYNE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27426 CHERRY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91354-2056
Mailing Address - Country:US
Mailing Address - Phone:661-297-3930
Mailing Address - Fax:
Practice Address - Street 1:1505 WILSON TER
Practice Address - Street 2:SUITE 200
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4071
Practice Address - Country:US
Practice Address - Phone:818-246-8974
Practice Address - Fax:818-246-7673
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT-18312363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT-18312OtherPHYSICIAN ASSISTANT