MEDICARE: MRS. MARY MOLINA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA13143	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA13143	OTHER	CA	SATE LIC. #

General Provider Information

NPI Number	:	1053484550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY MOLINA

Provider Business Mailing Address
First Line	:	2570 JENSEN AVE STE 106
Second Line	:
City	:	SANGER
State	:	CA
Zip	:	93657-2269
Country	:	US
Telephone Number	:	559-875-3428
Fax Number	:	559-875-3434

Provider Business Practice Location Address
First Line	:	2570 JENSEN AVE STE 106
Second Line	:
City	:	SANGER
State	:	CA
Zip	:	93657-2269
Country	:	US
Telephone Number	:	559-875-3428
Fax Number	:	559-875-3434

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	07/08/2007

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Directions to “ MRS. MARY MOLINA ” Practice Location

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