Provider Demographics
NPI:1205130739
Name:MOLLOY, MARY L (PA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:MOLLOY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:4371 VERONICA S SHOEMAKER BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-2216
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:239-278-3350
Practice Address - Street 1:8931 COLONIAL CENTER DR
Practice Address - Street 2:SUITE 300
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7809
Practice Address - Country:US
Practice Address - Phone:239-938-0800
Practice Address - Fax:239-938-0890
Is Sole Proprietor?:No
Enumeration Date:2010-12-23
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9105263363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant