Provider Demographics
NPI:1487633137
Name:VANAUSDOLL, MELISSA A (PAC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:VANAUSDOLL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602362
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2362
Mailing Address - Country:US
Mailing Address - Phone:704-537-0020
Mailing Address - Fax:704-537-2144
Practice Address - Street 1:7110 LAWYERS RD
Practice Address - Street 2:
Practice Address - City:MINT HILL
Practice Address - State:NC
Practice Address - Zip Code:28227-3906
Practice Address - Country:US
Practice Address - Phone:704-537-0020
Practice Address - Fax:704-537-2144
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103382363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101447Medicaid
NC2762394AMedicare PIN
KYD34186Medicare UPIN
NC8101447Medicaid