Provider Demographics
NPI:1164563912
Name:LIST, MELISSA BATENIC (MS, PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:BATENIC
Last Name:LIST
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:BATENIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, PA-C
Mailing Address - Street 1:2243 N LINCOLN AVE APT 3A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-3781
Mailing Address - Country:US
Mailing Address - Phone:312-550-2309
Mailing Address - Fax:
Practice Address - Street 1:3609 SW DURHAM DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-6507
Practice Address - Country:US
Practice Address - Phone:919-403-3051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002501363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical