Provider Demographics
NPI:1790864064
Name:FUSSELL, MELISSA MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:MARIE
Last Name:FUSSELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5612 WHITESVILLE RD STE A
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-9031
Mailing Address - Country:US
Mailing Address - Phone:706-322-2223
Mailing Address - Fax:706-324-5233
Practice Address - Street 1:5612 WHITESVILLE RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-9031
Practice Address - Country:US
Practice Address - Phone:706-322-2223
Practice Address - Fax:706-324-5233
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2019-08-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA004346363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA719264099AMedicaid
GA511I970308Medicare PIN
GA719264099AMedicaid
GAQ33102Medicare UPIN