Basic Information
| Provider Information | |||||||||
| NPI: | 1740697564 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOLESEVICH | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 DOCK HILL RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178428910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708372123 | ||||||||
| FaxNumber: | 5708372185 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 SUSQUEHANNA VALLEY MALL DR STE A | ||||||||
| Address2: | |||||||||
| City: | SELINSGROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178709148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703747852 | ||||||||
| FaxNumber: | 5703747932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2014 | ||||||||
| LastUpdateDate: | 09/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | OA003367 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | MA056915 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 103159304 | 05 | PA | MEDICAID |