Provider Demographics
NPI:1578566600
Name:EDDS, MELISSA DAWN (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:DAWN
Last Name:EDDS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0328
Mailing Address - Fax:502-587-4784
Practice Address - Street 1:4402 CHURCHMAN AVE STE 300
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-3101
Practice Address - Country:US
Practice Address - Phone:502-363-0588
Practice Address - Fax:502-363-0972
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA851363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1299470001OtherPTAN
KY7100172620Medicaid
KY0620406Medicare PIN
KYP57752Medicare UPIN
KY7100172620Medicaid
KY1299470001OtherPTAN