Provider Demographics
NPI:1902998974
Name:FANTON, MELISSA (RPA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:FANTON
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:MCINTOSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:210 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14141-1442
Mailing Address - Country:US
Mailing Address - Phone:716-592-3600
Mailing Address - Fax:716-592-3613
Practice Address - Street 1:210 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:14141-1442
Practice Address - Country:US
Practice Address - Phone:716-592-3600
Practice Address - Fax:716-592-3613
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011387363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03031436Medicaid
NY000529192003OtherBCBS
NY9514014OtherIHA
NY1902998974OtherUNIVERA
NYP00731283OtherRAILROAD MEDICARE
NYQ77359Medicare UPIN