Provider Demographics
NPI:1568099117
Name:BOGE, MOLLY ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:ELIZABETH
Last Name:BOGE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:ELIZABETH
Other - Last Name:ZIMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 LANGWORTHY ST
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-7365
Mailing Address - Country:US
Mailing Address - Phone:563-584-3490
Mailing Address - Fax:563-584-3177
Practice Address - Street 1:1000 LANGWORTHY ST
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-7365
Practice Address - Country:US
Practice Address - Phone:563-584-3490
Practice Address - Fax:563-584-3177
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IA102031363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program