Provider Demographics
NPI:1265461313
Name:DESTEFANO, MELISSA ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:DESTEFANO
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 1:16 MANOR AVE STE A
Mailing Address - Street 2:MANOR FAMILY HEALTH CENTER
Mailing Address - City:MILLERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17551-1132
Mailing Address - Country:US
Mailing Address - Phone:717-872-5444
Mailing Address - Fax:717-872-1537
Practice Address - Street 1:16 MANOR AVE STE A
Practice Address - Street 2:MANOR FAMILY HEALTH CENTER
Practice Address - City:MILLERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17551-1132
Practice Address - Country:US
Practice Address - Phone:717-872-5444
Practice Address - Fax:717-872-1537
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001961363AS0400X, 363AM0700X
PAMA053304363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA012972U92Medicare PIN
VAQ32566Medicare UPIN