Provider Demographics
NPI:1053757054
Name:HARTZLER, MOLLY AMANDA (MD)
Entity type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:AMANDA
Last Name:HARTZLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MOLLY
Other - Middle Name:AMANDA
Other - Last Name:KEEGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:ATTN CREDENTIALING/PAYER ENROLLMENT
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2510 AIRPARK DR STE 301
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-2462
Practice Address - Country:US
Practice Address - Phone:530-242-3500
Practice Address - Fax:530-242-3546
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2018-00633207X00000X
CAA162537207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC3384Medicaid
NC1053757054Medicaid
NC0397730024OtherNSC #