Provider Demographics
NPI:1538287982
Name:GOULD, MELANIE (PA)
Entity Type:Individual
Prefix:MISS
First Name:MELANIE
Middle Name:
Last Name:GOULD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:75 ITHACA AVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11509-1322
Mailing Address - Country:US
Mailing Address - Phone:917-805-1752
Mailing Address - Fax:516-239-6125
Practice Address - Street 1:4915 BROADWAY
Practice Address - Street 2:SUITE 1B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-3119
Practice Address - Country:US
Practice Address - Phone:212-567-9580
Practice Address - Fax:212-567-9582
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY011503363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY011503OtherLICENSE