Healthcare Provider Details

I. General information

NPI: 1275807422
Provider Name (Legal Business Name): MOLLY GRASSMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2012
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1699 S 14TH ST STE 16
FERNANDINA BEACH FL
32034-1965
US

IV. Provider business mailing address

5191 FIRST COAST TECH PKWY FL 3
JACKSONVILLE FL
32224-0609
US

V. Phone/Fax

Practice location:
  • Phone: 904-223-3321
  • Fax: 904-223-2169
Mailing address:
  • Phone: 904-223-3321
  • Fax: 904-223-2169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9121709
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: