Basic Information
| Provider Information | |||||||||
| NPI: | 1841625951 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WANNAMAKER | ||||||||
| FirstName: | MOLLYROSE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILEWSKI | ||||||||
| OtherFirstName: | MOLLYROSE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 289 OLMSTED BLVD | ||||||||
| Address2: | STE 5 | ||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104201282 | ||||||||
| FaxNumber: | 9104201116 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 GOODMAN ST | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134758787 | ||||||||
| FaxNumber: | 5134757348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2013 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 1968 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 0010-11376 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 50005855RX | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1986 | 01 | SC | SC LICENSE | OTHER | 379336601 | 05 | TX | MEDICAID |