MEDICARE: MR. JEROME MARK MOLSTAD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	15-00204	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578500286
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEROME MARK MOLSTAD

Provider Business Mailing Address
First Line	:	416 W 7TH
Second Line	:	PO BOX 8
City	:	LACROSSE
State	:	KS
Zip	:	67548
Country	:	US
Telephone Number	:	785-626-2626
Fax Number	:

Provider Business Practice Location Address
First Line	:	210 W 1ST ST
Second Line	:
City	:	SAINT FRANCIS
State	:	KS
Zip	:	67756-3540
Country	:	US
Telephone Number	:	785-332-2104
Fax Number	:	785-332-3255

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	07/21/2022

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Directions to “ MR. JEROME MARK MOLSTAD ” Practice Location

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