Provider Demographics
NPI:1679152896
Name:NYC, MARY ANN (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:NYC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY ANN
Other - Middle Name:
Other - Last Name:NYC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:420 N MCKINLEY ST STE 111-237
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-8099
Mailing Address - Country:US
Mailing Address - Phone:951-827-4568
Mailing Address - Fax:
Practice Address - Street 1:2101 N WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4836
Practice Address - Country:US
Practice Address - Phone:909-883-8711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA193007207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program