Provider Demographics
NPI:1841728623
Name:ANDERSON, MOLLY A (PA-C)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:A
Other - Last Name:MULLERVY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2360 E PERSHING BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-5356
Mailing Address - Country:US
Mailing Address - Phone:307-778-7550
Mailing Address - Fax:
Practice Address - Street 1:2360 E PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-5356
Practice Address - Country:US
Practice Address - Phone:307-778-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-24
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2150207Y00000X
WY1120363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology