MEDICARE: MARK TRISTAN FUCINARI CNIM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZE0600X	Electroneurodiagnostic Specialist/Technologist

General Provider Information

NPI Number	:	1639503600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK TRISTAN FUCINARI CNIM

Provider Business Mailing Address
First Line	:	4653 CARMEL MOUNTAIN RD STE 308-201
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92130-6650
Country	:	US
Telephone Number	:	619-955-8494
Fax Number	:

Provider Business Practice Location Address
First Line	:	4653 CARMEL MOUNTAIN RD STE 308-201
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92130-6650
Country	:	US
Telephone Number	:	619-955-8494
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/27/2013
Last Update Date	:	07/25/2014

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