Healthcare Provider Details

I. General information

NPI: 1639629314
Provider Name (Legal Business Name): MOLLY LATTA MONAHAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MOLLY ELIZABETH LATTA PA-C

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9898 GENESEE AVE 4TH FLOOR
LA JOLLA CA
92037
US

IV. Provider business mailing address

10790 RANCHO BERNARDO RD
SAN DIEGO CA
92127-5705
US

V. Phone/Fax

Practice location:
  • Phone: 858-824-5113
  • Fax:
Mailing address:
  • Phone: 858-824-5113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number57653
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: