Provider Demographics
NPI:1538153846
Name:GENTRY, MELISSA N (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:N
Last Name:GENTRY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:NOEL
Other - Last Name:VINK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1229 C AVE E
Mailing Address - Street 2:
Mailing Address - City:OSKALOOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52577-4246
Mailing Address - Country:US
Mailing Address - Phone:641-672-3159
Mailing Address - Fax:641-672-3259
Practice Address - Street 1:1229 C AVE E
Practice Address - Street 2:
Practice Address - City:OSKALOOSA
Practice Address - State:IA
Practice Address - Zip Code:52577-4246
Practice Address - Country:US
Practice Address - Phone:641-672-3159
Practice Address - Fax:641-672-3259
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001504363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1538153846OtherNPI
IAIB2309001Medicare PIN
1538153846OtherNPI