Provider Demographics
NPI:1376786764
Name:BERGHOFF, MELISSA ANN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:ANN
Last Name:BERGHOFF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5450 WESTERN AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2709
Mailing Address - Country:US
Mailing Address - Phone:303-415-8900
Mailing Address - Fax:303-443-6476
Practice Address - Street 1:2995 BASELINE RD
Practice Address - Street 2:SUITE 210
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-2318
Practice Address - Country:US
Practice Address - Phone:303-443-2544
Practice Address - Fax:303-443-6476
Is Sole Proprietor?:No
Enumeration Date:2009-04-14
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
COPA.0002713363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO91921791Medicaid
COC306080Medicare PIN