Provider Demographics
NPI:1053484550
Name:MOLINA, MARY
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:MOLINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2570 JENSEN AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:SANGER
Mailing Address - State:CA
Mailing Address - Zip Code:93657-2269
Mailing Address - Country:US
Mailing Address - Phone:559-875-3428
Mailing Address - Fax:559-875-3434
Practice Address - Street 1:2570 JENSEN AVE STE 106
Practice Address - Street 2:
Practice Address - City:SANGER
Practice Address - State:CA
Practice Address - Zip Code:93657-2269
Practice Address - Country:US
Practice Address - Phone:559-875-3428
Practice Address - Fax:559-875-3434
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13143363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA13143OtherSATE LIC. #