Provider Demographics
NPI:1255878054
Name:MOLITOR, JOHN WILLIAM JR (AGACNP)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:MOLITOR
Suffix:JR
Gender:M
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3009 N BALLAS RD STE 323A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2324
Mailing Address - Country:US
Mailing Address - Phone:314-942-2213
Mailing Address - Fax:314-942-2217
Practice Address - Street 1:3009 N BALLAS RD
Practice Address - Street 2:SUITE 323A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2322
Practice Address - Country:US
Practice Address - Phone:314-942-2213
Practice Address - Fax:314-942-2217
Is Sole Proprietor?:No
Enumeration Date:2017-01-31
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012010001363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner