Provider Demographics
NPI:1023469129
Name:JO, MOONSUNG (MS, ATC, LAT)
Entity type:Individual
Prefix:
First Name:MOONSUNG
Middle Name:
Last Name:JO
Suffix:
Gender:M
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 W RIO SALADO PKWY
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-3603
Mailing Address - Country:US
Mailing Address - Phone:617-755-4569
Mailing Address - Fax:
Practice Address - Street 1:2510 W RIO SALADO PKWY
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-3603
Practice Address - Country:US
Practice Address - Phone:617-755-4569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14882255A2300X
ORAT-AT-101712432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer