Provider Demographics
NPI:1639503600
Name:FUCINARI, MARK TRISTAN (CNIM)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:TRISTAN
Last Name:FUCINARI
Suffix:
Gender:M
Credentials:CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4653 CARMEL MOUNTAIN RD STE 308-201
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-6650
Mailing Address - Country:US
Mailing Address - Phone:619-955-8494
Mailing Address - Fax:
Practice Address - Street 1:4653 CARMEL MOUNTAIN RD STE 308-201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-6650
Practice Address - Country:US
Practice Address - Phone:619-955-8494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-27
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic