Provider Demographics
NPI:1790187441
Name:GOLDENBERG, MOLLIE B (PA-C)
Entity type:Individual
Prefix:
First Name:MOLLIE
Middle Name:B
Last Name:GOLDENBERG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MOLLIE
Other - Middle Name:E
Other - Last Name:BASH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:207-482-7898
Practice Address - Street 1:33 SEWALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2603
Practice Address - Country:US
Practice Address - Phone:207-828-2100
Practice Address - Fax:207-553-7166
Is Sole Proprietor?:No
Enumeration Date:2014-09-24
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000969363AS0400X
MEPA1636363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400339004Medicare PIN
MEE400339027Medicare PIN