Provider Demographics
NPI:1134804206
Name:JAVIER, MARK DENNIEL MACABUAG
Entity type:Individual
Prefix:
First Name:MARK DENNIEL
Middle Name:MACABUAG
Last Name:JAVIER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1453
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92074-1453
Mailing Address - Country:US
Mailing Address - Phone:858-335-0379
Mailing Address - Fax:
Practice Address - Street 1:14220 WOODCREEK RD
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-3350
Practice Address - Country:US
Practice Address - Phone:858-335-0379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA729618163WW0000X
CA95020784363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WW0000XNursing Service ProvidersRegistered NurseWound Care