Provider Demographics
NPI:1437283793
Name:HYATT, MARK A (CADC II)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:HYATT
Suffix:
Gender:M
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10556 COMBIE RD
Mailing Address - Street 2:PMB 6418
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95602-8908
Mailing Address - Country:US
Mailing Address - Phone:530-559-3524
Mailing Address - Fax:
Practice Address - Street 1:838 BEACH CT
Practice Address - Street 2:
Practice Address - City:COLOMA
Practice Address - State:CA
Practice Address - Zip Code:96513
Practice Address - Country:US
Practice Address - Phone:530-626-7252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18601206174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA18601206OtherCADCA