Provider Demographics
NPI:1639267255
Name:PEPPER, MELVIN BYRON (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MELVIN
Middle Name:BYRON
Last Name:PEPPER
Suffix:
Gender:M
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:S75W33050 ROLLING FIELDS DR
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-9311
Mailing Address - Country:US
Mailing Address - Phone:262-392-4002
Mailing Address - Fax:414-479-2515
Practice Address - Street 1:10400 W. NORTH AVE.
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-479-2513
Practice Address - Fax:414-479-2515
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1909-023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIM99824Medicare UPIN