Provider Demographics
NPI:1871826883
Name:REILLY, MOLLY SWALLOW (PA-C)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:SWALLOW
Last Name:REILLY
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 1:91 MONTVALE AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:91 MONTVALE AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3623
Practice Address - Country:US
Practice Address - Phone:781-279-1123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-09
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3870363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical