Healthcare Provider Details

I. General information

NPI: 1114078631
Provider Name (Legal Business Name): MARK OKAWACHI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MARK OKAWACHI PA-C

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 02/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 S MAIN ST
WALNUT CREEK CA
94596-5318
US

IV. Provider business mailing address

1022 ELM CT
EL CERRITO CA
94530-2602
US

V. Phone/Fax

Practice location:
  • Phone: 925-295-4130
  • Fax:
Mailing address:
  • Phone: 510-526-1612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC16009
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: