Provider Demographics
NPI:1548308398
Name:FAN, MELODY (PA-C)
Entity type:Individual
Prefix:MS
First Name:MELODY
Middle Name:
Last Name:FAN
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 1:1135 116TH AVE NE
Mailing Address - Street 2:SUITE 620
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004
Mailing Address - Country:US
Mailing Address - Phone:425-454-8016
Mailing Address - Fax:425-453-2827
Practice Address - Street 1:1135 116TH AVE NE
Practice Address - Street 2:SUITE 620
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004
Practice Address - Country:US
Practice Address - Phone:425-454-8016
Practice Address - Fax:425-453-2827
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004586363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Not Answered363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAQ12393Medicare UPIN
WA8802816Medicare ID - Type Unspecified