Basic Information
| Provider Information | |||||||||
| NPI: | 1093023749 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAGE | ||||||||
| FirstName: | MOLLIE | ||||||||
| MiddleName: | CARLSON | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6048 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977086048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413824900 | ||||||||
| FaxNumber: | 5417062398 | ||||||||
| Practice Location | |||||||||
| Address1: | 1501 NE MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413824900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2010 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA161402 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 500655511 | 05 | OR | MEDICAID |