Provider Demographics
NPI:1144669938
Name:MOORE, MOLLIE (PA-C, MSPAS, MPH)
Entity type:Individual
Prefix:
First Name:MOLLIE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PA-C, MSPAS, MPH
Other - Prefix:
Other - First Name:MOLLIE
Other - Middle Name:ANN
Other - Last Name:SCHNEIDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5800 NAVE DR STE F
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94949-6403
Practice Address - Country:US
Practice Address - Phone:415-483-4807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA23010363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical