Provider Demographics
NPI:1568056570
Name:REGENCY RECONSTRUCTION PLLC
Entity Type:Organization
Organization Name:REGENCY RECONSTRUCTION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-255-4794
Mailing Address - Street 1:10240 W INDIAN SCHOOL RD STE 115
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-5905
Mailing Address - Country:US
Mailing Address - Phone:623-243-9077
Mailing Address - Fax:
Practice Address - Street 1:3172 N SWAN RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-1227
Practice Address - Country:US
Practice Address - Phone:623-243-9077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGENCY RECONSTRUCTION PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-02-22
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ444652Medicaid