Provider Demographics
NPI:1568559250
Name:VANSICKEL, MELISSA R (PA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:R
Last Name:VANSICKEL
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 1:9695 S YOSEMITE ST STE 285
Mailing Address - Street 2:
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-2890
Mailing Address - Country:US
Mailing Address - Phone:303-649-3115
Mailing Address - Fax:303-649-3116
Practice Address - Street 1:9695 S YOSEMITE ST STE 285
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-2890
Practice Address - Country:US
Practice Address - Phone:303-649-3115
Practice Address - Fax:303-649-3116
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0003286363AM0700X
IA001724363AM0700X
CO0003286363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA001724OtherLICENSE
IA161801Medicare ID - Type UnspecifiedMEDICARE UGS