Provider Demographics
NPI:1093037798
Name:PEQUIGNOT, MELANIE L (PA)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:L
Last Name:PEQUIGNOT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:L
Other - Last Name:MILLIKAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:7910 W JEFFERSON BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4159
Mailing Address - Country:US
Mailing Address - Phone:260-436-4116
Mailing Address - Fax:260-436-1878
Practice Address - Street 1:7910 W JEFFERSON BLVD STE 110
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4159
Practice Address - Country:US
Practice Address - Phone:260-436-4116
Practice Address - Fax:260-436-1878
Is Sole Proprietor?:No
Enumeration Date:2010-02-22
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001156363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400071774Medicare PIN