Healthcare Provider Details

I. General information

NPI: 1588147250
Provider Name (Legal Business Name): MOLLY REQUE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 11/05/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3831 PIPER STREET STE S450
ANCHORAGE AK
99508
US

IV. Provider business mailing address

3831 PIPER STREET STE S450
ANCHORAGE AK
99508
US

V. Phone/Fax

Practice location:
  • Phone: 907-258-6999
  • Fax: 907-258-6247
Mailing address:
  • Phone: 907-258-6999
  • Fax: 907-258-6247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number157014
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: