Provider Demographics
NPI:1396512257
Name:MAAS, MOLLY GESSICA
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:GESSICA
Last Name:MAAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5642 SW IDAHO ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-1625
Mailing Address - Country:US
Mailing Address - Phone:805-368-4993
Mailing Address - Fax:
Practice Address - Street 1:3377 RIVERBEND DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-8803
Practice Address - Country:US
Practice Address - Phone:541-222-8400
Practice Address - Fax:541-222-8401
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-11
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10034685363LC0200X, 363LA2100X
CA95029029363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty