Provider Demographics
NPI:1164521076
Name:WHEELWRIGHT, MOLLY S (PAC)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:S
Last Name:WHEELWRIGHT
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:S
Other - Last Name:WHEELWRIGHT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PAC
Mailing Address - Street 1:58 W CUSHING ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85701
Mailing Address - Country:US
Mailing Address - Phone:520-620-0705
Mailing Address - Fax:
Practice Address - Street 1:58 W CUSHING ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85701
Practice Address - Country:US
Practice Address - Phone:520-620-0705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1372363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ152158Medicaid
P39779Medicare UPIN
AZ152158Medicaid