Provider Demographics
NPI:1649588914
Name:MILLER, MELISSA N (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:N
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:N
Other - Last Name:LIND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2809 N PARK DRIVE LN
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-1603
Mailing Address - Country:US
Mailing Address - Phone:920-380-4999
Mailing Address - Fax:
Practice Address - Street 1:2809 N PARK DRIVE LN
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-1603
Practice Address - Country:US
Practice Address - Phone:920-380-4999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003857363AM0700X
WI4250363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10115176OtherBCBSIL GROUP
IL363502461001OtherTRICARE
IL769380OtherMEDICARE GROUP PTAN