Provider Demographics
NPI:1497336408
Name:MOCK, MADISON TRACY (MLS(ASCP))
Entity Type:Individual
Prefix:MS
First Name:MADISON
Middle Name:TRACY
Last Name:MOCK
Suffix:
Gender:F
Credentials:MLS(ASCP)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1534 LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-3028
Mailing Address - Country:US
Mailing Address - Phone:406-241-1280
Mailing Address - Fax:
Practice Address - Street 1:3687 VETERANS DR
Practice Address - Street 2:
Practice Address - City:FORT HARRISON
Practice Address - State:MT
Practice Address - Zip Code:59636-9700
Practice Address - Country:US
Practice Address - Phone:406-442-6410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN11224282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural