Healthcare Provider Details

I. General information

NPI: 1679578991
Provider Name (Legal Business Name): MOLLY M CERNIGLIA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 07/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1955 W FRYE RD
CHANDLER AZ
85224-6282
US

IV. Provider business mailing address

6721 S JACQUELINE WAY
GILBERT AZ
85298
US

V. Phone/Fax

Practice location:
  • Phone: 608-782-2800
  • Fax:
Mailing address:
  • Phone: 608-397-3036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6356
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1821
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: