Provider Demographics
NPI:1467438465
Name:WITZIGMAN, MELISSA A (PA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:WITZIGMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N STATE OF FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6035
Mailing Address - Country:US
Mailing Address - Phone:423-302-1200
Mailing Address - Fax:423-302-1220
Practice Address - Street 1:400 N STATE OF FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6035
Practice Address - Country:US
Practice Address - Phone:423-302-1200
Practice Address - Fax:423-302-1220
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI772-023363A00000X
TN1846363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI005OtherBCBS
WI42952100Medicaid
TN1520451Medicaid
TN103I976355Medicare PIN
TN1520451Medicaid
WI020601940Medicare PIN
WI0043Medicare PIN
WI005OtherBCBS