Provider Demographics
NPI:1114900594
Name:MELMER, MICHAEL J (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MELMER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 4TH ST SE
Mailing Address - Street 2:
Mailing Address - City:HURON
Mailing Address - State:SD
Mailing Address - Zip Code:57350-2510
Mailing Address - Country:US
Mailing Address - Phone:605-353-6593
Mailing Address - Fax:605-353-6506
Practice Address - Street 1:172 4TH ST SE
Practice Address - Street 2:
Practice Address - City:HURON
Practice Address - State:SD
Practice Address - Zip Code:57350-2510
Practice Address - Country:US
Practice Address - Phone:605-353-6593
Practice Address - Fax:605-353-6506
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR019927367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5750022Medicaid
SD5750022Medicaid