Healthcare Provider Details

I. General information

NPI: 1780890194
Provider Name (Legal Business Name): MARK J CAYCO NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 CAMINO DEL RIO S
SAN DIEGO CA
92108-3538
US

IV. Provider business mailing address

34800 BOB WILSON DR
SAN DIEGO CA
92134-3538
US

V. Phone/Fax

Practice location:
  • Phone: 619-881-4500
  • Fax:
Mailing address:
  • Phone: 619-753-1145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number564081
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number564081
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: