Provider Demographics
NPI:1902653496
Name:MOSS, MYKAL
Entity type:Individual
Prefix:
First Name:MYKAL
Middle Name:
Last Name:MOSS
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 1:14276 E PLACITA RANCHO LOMA ALTA
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:AZ
Mailing Address - Zip Code:85641-2477
Mailing Address - Country:US
Mailing Address - Phone:520-833-2232
Mailing Address - Fax:
Practice Address - Street 1:3061 W LIBERTY TREE LN
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-1544
Practice Address - Country:US
Practice Address - Phone:520-833-2232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-02
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QL0900XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyLaboratory Management