Provider Demographics
NPI:1649681875
Name:PERSAUD, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:PERSAUD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 STATION PLZ N STE 428
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3819
Mailing Address - Country:US
Mailing Address - Phone:516-663-2066
Mailing Address - Fax:516-663-4655
Practice Address - Street 1:222 STATION PLZ N STE 428
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3819
Practice Address - Country:US
Practice Address - Phone:516-663-2066
Practice Address - Fax:516-663-4655
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-09
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017439363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant