Healthcare Provider Details

I. General information

NPI: 1275074700
Provider Name (Legal Business Name): MOLLED TRAVEL VACCINES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2017
Last Update Date: 08/04/2022
Certification Date: 08/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18001 N 79TH AVE SUITE A-14
GLENDALE AZ
85308-8388
US

IV. Provider business mailing address

668 N 44TH ST SUITE 100W
PHOENIX AZ
85008-6507
US

V. Phone/Fax

Practice location:
  • Phone: 877-358-8648
  • Fax: 877-877-6875
Mailing address:
  • Phone: 877-358-8648
  • Fax: 480-546-3421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. PAUL FISHBURN
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 480-646-9020