Provider Demographics
NPI:1598863045
Name:ANDERSON, MELISSA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:ANDERSON
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 1:1001 E PRIMROSE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5155
Mailing Address - Country:US
Mailing Address - Phone:417-875-3022
Mailing Address - Fax:417-875-3019
Practice Address - Street 1:3800 S NATIONAL AVE FL 4
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5209
Practice Address - Country:US
Practice Address - Phone:417-875-3755
Practice Address - Fax:417-875-3295
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002010564363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2002010564OtherSTATE LICENSE
MO97070Medicare ID - Type Unspecified
MOP51943Medicare UPIN