Provider Demographics
NPI:1710219456
Name:EVERETT, MELISSA MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MICHELLE
Last Name:EVERETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:MICHELLE
Other - Last Name:BURGET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:ELM AND CARLTON ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14263-0001
Mailing Address - Country:US
Mailing Address - Phone:716-845-2300
Mailing Address - Fax:716-845-3423
Practice Address - Street 1:ELM AND CARLTON STREETS
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14263
Practice Address - Country:US
Practice Address - Phone:716-845-2300
Practice Address - Fax:716-845-3423
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015714363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03487749Medicaid
NY03487749Medicaid