Provider Demographics
NPI:1467805986
Name:CONCEPCION, MELISA
Entity Type:Individual
Prefix:
First Name:MELISA
Middle Name:
Last Name:CONCEPCION
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 ST. ANTOINE UHC D MAILBOX# 226
Mailing Address - Street 2:UNIVERSITY PEDIATRICIANS
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201
Mailing Address - Country:US
Mailing Address - Phone:313-966-5051
Mailing Address - Fax:313-966-0665
Practice Address - Street 1:3950 BEAUBIEN
Practice Address - Street 2:SPECIALTY CENTER/
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-832-8871
Practice Address - Fax:313-745-2405
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007742363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant