Provider Demographics
NPI:1083494090
Name:CHEKOL, MOGES KASSA
Entity Type:Individual
Prefix:
First Name:MOGES
Middle Name:KASSA
Last Name:CHEKOL
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 1:6315 W WARNER ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85043-0139
Mailing Address - Country:US
Mailing Address - Phone:312-619-7306
Mailing Address - Fax:
Practice Address - Street 1:6315 W WARNER ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85043-0139
Practice Address - Country:US
Practice Address - Phone:312-619-7306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-05
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9574363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant