Provider Demographics
NPI:1588785752
Name:SIMS, MARK RANDALL (CCP)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:RANDALL
Last Name:SIMS
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4950 PENINSULA POINT DR
Mailing Address - Street 2:
Mailing Address - City:SEASIDE
Mailing Address - State:CA
Mailing Address - Zip Code:93955-6509
Mailing Address - Country:US
Mailing Address - Phone:831-324-0589
Mailing Address - Fax:650-615-9995
Practice Address - Street 1:4950 PENINSULA POINT DR
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:CA
Practice Address - Zip Code:93955-6509
Practice Address - Country:US
Practice Address - Phone:831-324-0589
Practice Address - Fax:650-615-9995
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA930251242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist