Provider Demographics
NPI:1649554361
Name:PETERSEN, MOLLIE PFEIFER (PAC)
Entity type:Individual
Prefix:
First Name:MOLLIE
Middle Name:PFEIFER
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 S 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-1401
Mailing Address - Country:US
Mailing Address - Phone:920-743-5566
Mailing Address - Fax:
Practice Address - Street 1:1843 MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-1007
Practice Address - Country:US
Practice Address - Phone:920-746-1060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-29
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2806363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant