Provider Demographics
NPI:1689905689
Name:HALL, MELISSA K (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:K
Last Name:HALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:K
Other - Last Name:EDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2725 S 144TH ST
Mailing Address - Street 2:#110
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-5243
Mailing Address - Country:US
Mailing Address - Phone:402-637-0400
Mailing Address - Fax:402-637-0401
Practice Address - Street 1:2725 S 144TH ST
Practice Address - Street 2:#110
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-5243
Practice Address - Country:US
Practice Address - Phone:402-637-0400
Practice Address - Fax:402-637-0401
Is Sole Proprietor?:No
Enumeration Date:2010-01-15
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1484363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI8352006Medicare PIN
NE092169007Medicare PIN