Provider Demographics
NPI:1457784639
Name:BRITZ, MOLLY (PA-C)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:BRITZ
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 1:251 COUNTY ROAD 120
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4872
Mailing Address - Country:US
Mailing Address - Phone:320-202-8949
Mailing Address - Fax:320-202-0756
Practice Address - Street 1:251 COUNTY ROAD 120
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4872
Practice Address - Country:US
Practice Address - Phone:320-202-8949
Practice Address - Fax:320-202-0756
Is Sole Proprietor?:No
Enumeration Date:2013-08-12
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1962363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1457784639Medicaid
MNH400093175Medicare PIN