Provider Demographics
NPI:1073965240
Name:MORTENSON, MOLLIE MARGARET (PA-C)
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:MARGARET
Last Name:MORTENSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MOLLIE
Other - Middle Name:MARGARET
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6001 WESTOWN PKWY
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-7702
Mailing Address - Country:US
Mailing Address - Phone:515-224-1414
Mailing Address - Fax:515-224-5140
Practice Address - Street 1:6001 WESTOWN PKWY
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-7719
Practice Address - Country:US
Practice Address - Phone:515-224-1414
Practice Address - Fax:515-224-5140
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA083211363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant