Provider Demographics
NPI:1083298301
Name:REGENCY SKIN INSTITUTE PLLC
Entity Type:Organization
Organization Name:REGENCY SKIN INSTITUTE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MUSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-251-6431
Mailing Address - Street 1:14725 W MOUNTAIN VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-2704
Mailing Address - Country:US
Mailing Address - Phone:623-243-9077
Mailing Address - Fax:
Practice Address - Street 1:14725 W MOUNTAIN VIEW BLVD
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-2704
Practice Address - Country:US
Practice Address - Phone:623-243-9077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGENCY PATHOLOGY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ49090OtherARIZONA MEDICAL BOARD