Provider Demographics
NPI:1770953861
Name:HORNER, MOLLY JEAN (PA)
Entity type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:JEAN
Last Name:HORNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:MOLLY
Other - Middle Name:JEAN
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVENUE BOX 668
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 LATTIMORE RD STE 258
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-4155
Practice Address - Country:US
Practice Address - Phone:585-442-8020
Practice Address - Fax:585-442-8039
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060497363A00000X
NY19179363A00000X
363AM0700X
NY019179363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical