Provider Demographics
NPI:1790187441
Name:GOLDENBERG, MOLLIE B (PA-C)
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:B
Last Name:GOLDENBERG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MOLLIE
Other - Middle Name:E
Other - Last Name:BASH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:190 RIVERSIDE ST
Mailing Address - Street 2:SUITE 6B
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1073
Mailing Address - Country:US
Mailing Address - Phone:207-661-2000
Mailing Address - Fax:
Practice Address - Street 1:15 GRACELAWN RD STE 101
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-6347
Practice Address - Country:US
Practice Address - Phone:207-333-4710
Practice Address - Fax:207-333-4715
Is Sole Proprietor?:No
Enumeration Date:2014-09-24
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000969363AS0400X
MEPA1636363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400339004Medicare PIN
MEE400339027Medicare PIN