Provider Demographics
NPI:1841625951
Name:WANNAMAKER, MOLLYROSE M (PA-C)
Entity type:Individual
Prefix:MS
First Name:MOLLYROSE
Middle Name:M
Last Name:WANNAMAKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MOLLYROSE
Other - Middle Name:
Other - Last Name:MILEWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:289 OLMSTED BLVD
Mailing Address - Street 2:STE 5
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8730
Mailing Address - Country:US
Mailing Address - Phone:910-420-1282
Mailing Address - Fax:910-420-1116
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219
Practice Address - Country:US
Practice Address - Phone:513-475-8787
Practice Address - Fax:513-475-7348
Is Sole Proprietor?:No
Enumeration Date:2013-09-08
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1968363AS0400X
NC0010-11376363AS0400X
OH50005855RX363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1986OtherSC LICENSE
TX379336601Medicaid