Provider Demographics
NPI:1427103365
Name:WILKINSON, MARY ANN (G067652)
Entity type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:WILKINSON
Suffix:
Gender:F
Credentials:G067652
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23961 CALLE DE LA MAGDALENA STE 334
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3665
Mailing Address - Country:US
Mailing Address - Phone:949-951-5437
Mailing Address - Fax:949-951-2715
Practice Address - Street 1:23961 CALLE DE LA MAGDALENA STE 334
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3665
Practice Address - Country:US
Practice Address - Phone:949-951-5437
Practice Address - Fax:949-951-2715
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0676522080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine