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General NPI Number Information
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NPI Number | 1124582374
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Entity Type | Individual
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Provider Name | MARK ELIASSON RRT, RPSGT
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Gender | Male
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Dates
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Enumeration Date | 01/22/2019
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Last Update Date | 12/30/2021
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Provider Practice Location Address
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Address Line | 975 SERENO DR
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City | VALLEJO
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State | CA
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Zip | 94589-2441
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Country | US
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Telephone | 707-651-2321
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Fax |
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Provider Business Mailing Address
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Address Line | 4437 ROCKWOOD AVE
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City | NAPA
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State | CA
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Zip | 94558-1762
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Country | US
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Telephone | 707-363-7894
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 227900000X
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Taxonomy Name | Registered Respiratory Therapist
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License Number | 12193
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License Number State | CA
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