Provider Demographics
NPI:1558578641
Name:PAULSON, MOLLY JEAN (PAC)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:JEAN
Last Name:PAULSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2126 3 MILE RD NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-3442
Mailing Address - Country:US
Mailing Address - Phone:616-363-9280
Mailing Address - Fax:
Practice Address - Street 1:2849 MICHIGAN ST NE
Practice Address - Street 2:SUITE 102
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1216
Practice Address - Country:US
Practice Address - Phone:616-285-6450
Practice Address - Fax:616-285-6455
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003048363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601003048OtherPHYSICIAN ASSISTANT LICEN
MP0852651OtherDEA CONT SUB CERTIFICATE