Basic Information
| Provider Information | |||||||||
| NPI: | 1104291426 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAKEFIELD | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4022 VIA ALDEA | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920576432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604532526 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1738 S TREMONT ST | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920545309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604392800 | ||||||||
| FaxNumber: | 7604335031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2015 | ||||||||
| LastUpdateDate: | 12/17/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 525200 | CA | Y | Nursing Service Providers | Registered Nurse |
No ID Information.