Healthcare Provider Details

I. General information

NPI: 1437283793
Provider Name (Legal Business Name): MARK A HYATT CADC II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 11/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

838 BEACH CT
COLOMA CA
96513
US

IV. Provider business mailing address

10556 COMBIE RD PMB 6418
AUBURN CA
95602-8908
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-7252
  • Fax:
Mailing address:
  • Phone: 530-559-3524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number18601206
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: