Provider Demographics
NPI:1053724542
Name:MOCK, EDWARD KEVIN JR (CMA)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:KEVIN
Last Name:MOCK
Suffix:JR
Gender:M
Credentials:CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6207 DIFFIN RD
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039-9399
Mailing Address - Country:US
Mailing Address - Phone:315-420-7272
Mailing Address - Fax:
Practice Address - Street 1:98 N 2ND ST
Practice Address - Street 2:SUITE 100
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-1254
Practice Address - Country:US
Practice Address - Phone:315-326-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide