Healthcare Provider Details

I. General information

NPI: 1053484550
Provider Name (Legal Business Name): MRS. MARY MOLINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2570 JENSEN AVE STE 106
SANGER CA
93657-2269
US

IV. Provider business mailing address

2570 JENSEN AVE STE 106
SANGER CA
93657-2269
US

V. Phone/Fax

Practice location:
  • Phone: 559-875-3428
  • Fax: 559-875-3434
Mailing address:
  • Phone: 559-875-3428
  • Fax: 559-875-3434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA13143
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: