Provider Demographics
NPI:1104822493
Name:BURNETT, MELINEE D (PA)
Entity Type:Individual
Prefix:MS
First Name:MELINEE
Middle Name:D
Last Name:BURNETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 MCHENRY ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1828
Mailing Address - Country:US
Mailing Address - Phone:262-767-8100
Mailing Address - Fax:
Practice Address - Street 1:252 MCHENRY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105
Practice Address - Country:US
Practice Address - Phone:262-767-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1347-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41986500Medicaid
WI000732115Medicare ID - Type UnspecifiedWAUK CNTY
WIP00171464Medicare ID - Type UnspecifiedRAILROAD MEDICARE
WI000845250Medicare ID - Type UnspecifiedAPPLETON CNTY
WI41986500Medicaid
WI000901702Medicare ID - Type UnspecifiedMILW CNTY