Provider Demographics
NPI:1124352604
Name:BERG, MOLLIE J (PA-C)
Entity type:Individual
Prefix:
First Name:MOLLIE
Middle Name:J
Last Name:BERG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MOLLIE
Other - Middle Name:J
Other - Last Name:BAESEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:512 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4147
Mailing Address - Country:US
Mailing Address - Phone:715-847-2021
Mailing Address - Fax:
Practice Address - Street 1:512 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4147
Practice Address - Country:US
Practice Address - Phone:715-847-2021
Practice Address - Fax:715-847-2325
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2496023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical