Provider Demographics
NPI:1437674793
Name:WOLF, MONICA FAYE (PA)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:FAYE
Last Name:WOLF
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MONICA
Other - Middle Name:FAYE
Other - Last Name:MILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:255 BAPTIST BLVD STE 401
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705
Practice Address - Country:US
Practice Address - Phone:662-244-2288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00434363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical