MEDICARE: MOLLIE WOLFE PA-C

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	PA9117374	FL

General Provider Information

NPI Number	:	1598454712
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOLLIE WOLFE PA-C

Provider Business Mailing Address
First Line	:	4758 CUMBERLAND STATION CT
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32257-5111
Country	:	US
Telephone Number	:	912-614-6465
Fax Number	:	904-329-2303

Provider Business Practice Location Address
First Line	:	8823 SAN JOSE BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32217-4287
Country	:	US
Telephone Number	:	904-404-7044
Fax Number	:	904-329-2303

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

Provider Enumeration Date	:	05/03/2023
Last Update Date	:	05/03/2023

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