Provider Demographics
NPI:1205544152
Name:KOMMER, MOLLY ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:ROSE
Last Name:KOMMER
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 1:17216 N 33RD AVE APT 2033
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-7804
Mailing Address - Country:US
Mailing Address - Phone:925-323-5322
Mailing Address - Fax:
Practice Address - Street 1:14502 W MEEKER BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-5282
Practice Address - Country:US
Practice Address - Phone:623-524-8767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-09
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9390207PE0004X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services