Provider Demographics
NPI:1437713930
Name:O'BRIEN, MOLLY (PA-C)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 PFINGSTEN RD
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-1301
Mailing Address - Country:US
Mailing Address - Phone:847-657-5815
Mailing Address - Fax:847-657-3724
Practice Address - Street 1:2100 PFINGSTEN RD
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-1301
Practice Address - Country:US
Practice Address - Phone:847-657-5815
Practice Address - Fax:847-657-3724
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-30
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085007099363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty