Provider Demographics
NPI:1841683562
Name:MOSKO, MALLORY NABER (PA-C)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:NABER
Last Name:MOSKO
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:M
Other - Last Name:MOSKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 636324
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6324
Mailing Address - Country:US
Mailing Address - Phone:859-301-2273
Mailing Address - Fax:859-301-6182
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-301-2273
Practice Address - Fax:859-301-6182
Is Sole Proprietor?:No
Enumeration Date:2015-03-05
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1992363A00000X
OH004112363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant