Provider Demographics
NPI:1710231139
Name:JOHNSON, MELISSA D (PA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:D
Other - Last Name:MCBRYDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1965 S FREMONT AVE STE 370
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2284
Mailing Address - Country:US
Mailing Address - Phone:417-820-0300
Mailing Address - Fax:
Practice Address - Street 1:1965 S FREMONT AVE STE 370
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2284
Practice Address - Country:US
Practice Address - Phone:417-820-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-07
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017033363363A00000X
MO201703363363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1710231139Medicaid
AK1620511Medicaid