Provider Demographics
NPI:1073102109
Name:MISTAL, MARK SCOTT (RN)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:SCOTT
Last Name:MISTAL
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 FLEMING COURT
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591
Mailing Address - Country:US
Mailing Address - Phone:707-400-4373
Mailing Address - Fax:
Practice Address - Street 1:815 FLEMING COURT
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94591
Practice Address - Country:US
Practice Address - Phone:707-400-4373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA451493163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice