Provider Demographics
NPI:1861792012
Name:KAGARISE, MELISSA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:KAGARISE
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 1:219 MALLARD LN
Mailing Address - Street 2:
Mailing Address - City:DUNCANSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16635-4555
Mailing Address - Country:US
Mailing Address - Phone:814-695-3032
Mailing Address - Fax:
Practice Address - Street 1:2525 9TH AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-2014
Practice Address - Country:US
Practice Address - Phone:814-201-2309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA-002061L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant