Provider Demographics
NPI:1598107484
Name:HICKEY, MOLLY KATHLEEN (PAC)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:KATHLEEN
Last Name:HICKEY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:KATHLEEN
Other - Last Name:COTRONEO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:2355 HWY 36 W.
Mailing Address - Street 2:STE. 100
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:651-292-2000
Mailing Address - Fax:
Practice Address - Street 1:2355 HWY 36 W.
Practice Address - Street 2:STE. 100
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113
Practice Address - Country:US
Practice Address - Phone:651-292-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-22
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3406-23363AS0400X
MN11577363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical