Provider Demographics
NPI:1518936756
Name:SULLIVAN, MELINDA CHRISTINE (MPAS PAC)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:CHRISTINE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MPAS PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10663 RAYSTOWN RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:HUNTINGDON
Mailing Address - State:PA
Mailing Address - Zip Code:16652-7542
Mailing Address - Country:US
Mailing Address - Phone:814-627-0071
Mailing Address - Fax:814-627-0315
Practice Address - Street 1:10663 RAYSTOWN RD
Practice Address - Street 2:SUITE B
Practice Address - City:HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:16652-7542
Practice Address - Country:US
Practice Address - Phone:814-627-0071
Practice Address - Fax:814-627-0315
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA00077L363A00000X
PAMA002783L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008434780002Medicaid
Q23423Medicare UPIN
393824Medicare ID - Type Unspecified