Provider Demographics
NPI:1124008016
Name:MUCKALA, TONI DENISE (PA-C, PHARMD)
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:DENISE
Last Name:MUCKALA
Suffix:
Gender:F
Credentials:PA-C, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5318 E HERMOSA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-1909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6739 W CACTUS RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5311
Practice Address - Country:US
Practice Address - Phone:833-242-0100
Practice Address - Fax:623-889-0814
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118389183500000X
MN9530363AM0700X
AZ5698363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No183500000XPharmacy Service ProvidersPharmacist
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN388528300Medicaid
MN9530OtherSTATE OF MINNESOTA PA LICENSE
AZ5698OtherSTATE OF ARIZONA PA LICENSE
MN388528300Medicaid
MN970002045Medicare ID - Type Unspecified