Provider Demographics
NPI:1790037042
Name:SMIRNOW, MELISSA ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:SMIRNOW
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 1:347 MOUNT PLEASANT AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052
Mailing Address - Country:US
Mailing Address - Phone:973-571-2121
Mailing Address - Fax:
Practice Address - Street 1:347 MOUNT PLEASANT AVE
Practice Address - Street 2:UNIT 103
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052
Practice Address - Country:US
Practice Address - Phone:973-571-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00296000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant