Provider Demographics
NPI:1578500286
Name:MOLSTAD, JEROME MARK
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:MARK
Last Name:MOLSTAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 W 7TH
Mailing Address - Street 2:PO BOX 8
Mailing Address - City:LACROSSE
Mailing Address - State:KS
Mailing Address - Zip Code:67548
Mailing Address - Country:US
Mailing Address - Phone:785-626-2626
Mailing Address - Fax:
Practice Address - Street 1:210 W 1ST ST
Practice Address - Street 2:
Practice Address - City:SAINT FRANCIS
Practice Address - State:KS
Practice Address - Zip Code:67756-3540
Practice Address - Country:US
Practice Address - Phone:785-332-2104
Practice Address - Fax:785-332-3255
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00204363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100414790AMedicaid
KS100414790AMedicaid
KS101466Medicare ID - Type Unspecified