Provider Demographics
NPI:1487657987
Name:NINEFELDT, MELINDA R (PA-C)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:R
Last Name:NINEFELDT
Suffix:
Gender:F
Credentials:PA-C
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 116
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:MN
Mailing Address - Zip Code:55726-0116
Mailing Address - Country:US
Mailing Address - Phone:218-644-3811
Mailing Address - Fax:218-644-3813
Practice Address - Street 1:206 MAIN ST. E.
Practice Address - Street 2:
Practice Address - City:HINCKLEY
Practice Address - State:MN
Practice Address - Zip Code:55037
Practice Address - Country:US
Practice Address - Phone:320-384-6618
Practice Address - Fax:320-384-6635
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9184363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN620586100Medicaid
MNP60755Medicare UPIN
MN970001353Medicare PIN