Provider Demographics
NPI:1376754044
Name:MODDRELL, MELISSA L (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
Last Name:MODDRELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:BIGGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4000 CAMBRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66160-3197
Mailing Address - Country:US
Mailing Address - Phone:913-588-5000
Mailing Address - Fax:312-695-1903
Practice Address - Street 1:4000 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-3197
Practice Address - Country:US
Practice Address - Phone:913-588-5000
Practice Address - Fax:312-695-1903
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002953363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085-002953OtherIL STATE LIC
KS15-02370OtherKANSAS STATE PA LICENSE