Provider Demographics
NPI:1801130893
Name:NOTBOHM, MOLLY JEAN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:JEAN
Last Name:NOTBOHM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:JEAN
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:12311 PERRY HWY
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-8344
Mailing Address - Country:US
Mailing Address - Phone:878-332-4387
Mailing Address - Fax:412-332-4490
Practice Address - Street 1:12311 PERRY HWY
Practice Address - Street 2:
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-8344
Practice Address - Country:US
Practice Address - Phone:878-332-4387
Practice Address - Fax:412-332-4490
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055861363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103162687Medicaid
12482518OtherCAQH