Provider Demographics
NPI:1518963073
Name:PACKWOOD, MELISSA D (PA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:D
Last Name:PACKWOOD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY
Mailing Address - Street 2:SUITE 129
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5132
Mailing Address - Country:US
Mailing Address - Phone:502-253-4917
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:3940 DUPONT CIR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4806
Practice Address - Country:US
Practice Address - Phone:502-895-1111
Practice Address - Fax:502-895-1085
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KYPA760363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY600673930WOtherHUMANA
KY0701078OtherUNITED HEALTHCARE
KY50001576OtherPASSPORT
KYP00466690OtherRR MEDICARE
KY95003711Medicaid
KY0701078OtherUNITED HEALTHCARE
KY0928404Medicare PIN