Provider Demographics
NPI:1720625080
Name:MOSCOSO, JACKSON ARIEL (SURGICAL ASSISTANT)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:ARIEL
Last Name:MOSCOSO
Suffix:
Gender:M
Credentials:SURGICAL ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3127 PLANTATION PKWY
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2117
Mailing Address - Country:US
Mailing Address - Phone:571-594-8144
Mailing Address - Fax:
Practice Address - Street 1:3127 PLANTATION PKWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2117
Practice Address - Country:US
Practice Address - Phone:571-594-8144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-05
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA5092246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Single Specialty