Provider Demographics
NPI:1396216230
Name:DA COSTA, MELANIE (PA-C)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:DA COSTA
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 1:131 S FEDERAL HWY APT 106
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-4906
Mailing Address - Country:US
Mailing Address - Phone:954-608-2889
Mailing Address - Fax:
Practice Address - Street 1:3100 S FEDERAL HWY STE J
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33483-3321
Practice Address - Country:US
Practice Address - Phone:561-320-8719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111633363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant