Provider Demographics
NPI:1093793846
Name:GLASSER-EDWARDS, MELISSA LYNNE (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LYNNE
Last Name:GLASSER-EDWARDS
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 1:1250 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738-7074
Mailing Address - Country:US
Mailing Address - Phone:989-348-0550
Mailing Address - Fax:989-348-0473
Practice Address - Street 1:1250 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-7074
Practice Address - Country:US
Practice Address - Phone:989-348-0550
Practice Address - Fax:989-348-0473
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003707363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1019683OtherNORTHERN HEALTH PLAN
P48121Medicare UPIN