Provider Demographics
NPI:1558666073
Name:BERG, MOLLIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MOLLIE
Middle Name:
Last Name:BERG
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 1:7045 YOUREE DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5108
Mailing Address - Country:US
Mailing Address - Phone:318-798-3763
Mailing Address - Fax:318-798-2267
Practice Address - Street 1:7045 YOUREE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5108
Practice Address - Country:US
Practice Address - Phone:318-798-3763
Practice Address - Fax:318-798-2267
Is Sole Proprietor?:No
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200396363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant