Healthcare Provider Details

I. General information

NPI: 1124582374
Provider Name (Legal Business Name): MARK ELIASSON RRT, RPSGT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 12/30/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 SERENO DR
VALLEJO CA
94589-2441
US

IV. Provider business mailing address

4437 ROCKWOOD AVE
NAPA CA
94558-1762
US

V. Phone/Fax

Practice location:
  • Phone: 707-651-2321
  • Fax:
Mailing address:
  • Phone: 707-363-7894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number12193
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: