Provider Demographics
NPI:1073006672
Name:SMITH, MOLLY BEADLE (PA-C)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:BEADLE
Last Name:SMITH
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 1:3100 W LAKE ST UNIT 527
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2098
Mailing Address - Country:US
Mailing Address - Phone:612-670-0747
Mailing Address - Fax:
Practice Address - Street 1:5400 EXCELSIOR BLVD STE 150
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2913
Practice Address - Country:US
Practice Address - Phone:952-993-1000
Practice Address - Fax:952-993-1160
Is Sole Proprietor?:No
Enumeration Date:2018-06-08
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14341363AS0400X, 363A00000X
IL085008251363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant