Provider Demographics
NPI:1407033012
Name:FULLNER-MARSHALL, MELISSA A (PA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:FULLNER-MARSHALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:FULLNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1104 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-3306
Mailing Address - Country:US
Mailing Address - Phone:605-665-7841
Mailing Address - Fax:605-665-0546
Practice Address - Street 1:1104 W 8TH ST
Practice Address - Street 2:
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-3306
Practice Address - Country:US
Practice Address - Phone:605-665-7841
Practice Address - Fax:605-665-0546
Is Sole Proprietor?:No
Enumeration Date:2008-01-25
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1632363AM0700X
SD0667363AM0700X
SD1222363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025938900Medicaid
SD6830000Medicaid
SD6830000Medicaid
SDS102298Medicare PIN