Provider Demographics
NPI:1144521170
Name:ANDERSON, MELISSA SUE (PA-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 427
Mailing Address - Street 2:
Mailing Address - City:HILLMAN
Mailing Address - State:MI
Mailing Address - Zip Code:49746-0427
Mailing Address - Country:US
Mailing Address - Phone:989-354-2197
Mailing Address - Fax:989-354-1952
Practice Address - Street 1:15774 STATE ST
Practice Address - Street 2:
Practice Address - City:HILLMAN
Practice Address - State:MI
Practice Address - Zip Code:49746-7961
Practice Address - Country:US
Practice Address - Phone:989-742-4583
Practice Address - Fax:989-742-2183
Is Sole Proprietor?:No
Enumeration Date:2010-11-08
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA001242363AM0700X
WAPA60229706363A00000X
MI1144521170363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF060160101Medicare PIN
MEP00899891Medicare PIN