Provider Demographics
NPI:1407247828
Name:ZACKOWSKI, MELINDA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:
Last Name:ZACKOWSKI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MELINDA
Other - Middle Name:
Other - Last Name:LACKORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6036 CHAMPIONS CREST DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-6252
Mailing Address - Country:US
Mailing Address - Phone:757-335-2227
Mailing Address - Fax:
Practice Address - Street 1:5100 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43228-1607
Practice Address - Country:US
Practice Address - Phone:614-544-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05583363A00000X
OH50005095RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant