Healthcare Provider Details

I. General information

NPI: 1134804206
Provider Name (Legal Business Name): MARK DENNIEL MACABUAG JAVIER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2023
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14220 WOODCREEK RD
POWAY CA
92064-3350
US

IV. Provider business mailing address

14220 WOODCREEK RD
POWAY CA
92064-3350
US

V. Phone/Fax

Practice location:
  • Phone: 858-335-0379
  • Fax:
Mailing address:
  • Phone: 858-335-0379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95020784
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number729618
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95020784
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: