Provider Demographics
NPI:1497788517
Name:MARANTO, MOLLY HENDERSON (PA-C)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:HENDERSON
Last Name:MARANTO
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 1:2539 VIKING DR STE 101
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2165
Mailing Address - Country:US
Mailing Address - Phone:318-747-8100
Mailing Address - Fax:318-747-8150
Practice Address - Street 1:2539 VIKING DR STE 101
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2165
Practice Address - Country:US
Practice Address - Phone:318-747-8100
Practice Address - Fax:318-747-8150
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA20017207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1627739Medicaid
LA5F600P658Medicare ID - Type Unspecified
LAQ41977Medicare UPIN