MEDICARE: REGENCY SKIN INSTITUTE PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ND0101X	MOHS-Micrographic Surgery Physician	49090	AZ

General Provider Information

NPI Number	:	1932630563
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REGENCY SKIN INSTITUTE PLLC

Provider Business Mailing Address
First Line	:	10240 W INDIAN SCHOOL RD
Second Line	:	SUITE 115
City	:	PHOENIX
State	:	AZ
Zip	:	85037-5904
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	14725 W MOUNTAIN VIEW BLVD
Second Line	:
City	:	SURPRISE
State	:	AZ
Zip	:	85374-2704
Country	:	US
Telephone Number	:	623-243-9077
Fax Number	:

Authorized Official
Title or Position	:	PLASTIC SURGEON
Name	:	JASON LEE MUSSMAN
Credential	:	M.D.
Telephone Number	:	989-255-4794

Provider Enumeration Date	:	03/24/2017
Last Update Date	:	05/02/2025

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