Provider Demographics
NPI:1336383280
Name:WHEELER, MOLLY ANNA (PA-C)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:ANNA
Last Name:WHEELER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:ANNA
Other - Last Name:DOWNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:125 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3303
Mailing Address - Country:US
Mailing Address - Phone:920-262-4449
Mailing Address - Fax:920-262-4533
Practice Address - Street 1:2122 HEALTH DR SW STE 133
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9698
Practice Address - Country:US
Practice Address - Phone:616-252-5950
Practice Address - Fax:616-252-5956
Is Sole Proprietor?:No
Enumeration Date:2009-04-22
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005475363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601005475OtherMICHIGAN BOARD OF MEDICINE
MI5601005475OtherSTATE LICENSE NUMBER