Provider Demographics
NPI:1144558107
Name:MELCHIONDA, LARA (PA-C)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:MELCHIONDA
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 1:21 HIGHLAND AVE
Mailing Address - Street 2:SUITE 3-4A
Mailing Address - City:NEWBURYPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01950-3872
Mailing Address - Country:US
Mailing Address - Phone:978-462-8300
Mailing Address - Fax:978-462-8301
Practice Address - Street 1:21 HIGHLAND AVE
Practice Address - Street 2:SUITE 3-4A
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-3872
Practice Address - Country:US
Practice Address - Phone:978-462-8300
Practice Address - Fax:978-462-8301
Is Sole Proprietor?:No
Enumeration Date:2009-12-02
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
MEPA001238363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPA3916OtherLICENSE