Provider Demographics
NPI:1508093287
Name:NIX, MALISSA (PA)
Entity Type:Individual
Prefix:MS
First Name:MALISSA
Middle Name:
Last Name:NIX
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 1:4425 PAULSEN ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-3637
Mailing Address - Country:US
Mailing Address - Phone:912-525-1314
Mailing Address - Fax:912-354-5970
Practice Address - Street 1:4425 PAULSEN ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-3637
Practice Address - Country:US
Practice Address - Phone:912-525-1314
Practice Address - Fax:912-354-5970
Is Sole Proprietor?:No
Enumeration Date:2009-06-19
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4680363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA027147597BMedicaid
GA027147597BMedicaid