Provider Demographics
NPI:1326014218
Name:KELLER, MELISSA RENEE (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:RENEE
Last Name:KELLER
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 1:6071 W OUTER DR
Mailing Address - Street 2:DEPARTMENT OF SURGERY
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-2624
Mailing Address - Country:US
Mailing Address - Phone:313-966-3300
Mailing Address - Fax:313-966-4773
Practice Address - Street 1:6071 W OUTER DR
Practice Address - Street 2:DEPARTMENT OF SURGERY
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2624
Practice Address - Country:US
Practice Address - Phone:313-966-3300
Practice Address - Fax:313-966-4773
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004036363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N33470055Medicare ID - Type Unspecified
MIP97590Medicare UPIN
MIP35120151Medicare PIN