Provider Demographics
NPI:1790940146
Name:WHITAKER, MELISSA BLAIR (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:BLAIR
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:BLAIR
Other - Middle Name:
Other - Last Name:WHITAKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:2616 LEGENDS WAY
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-2418
Mailing Address - Country:US
Mailing Address - Phone:859-331-3100
Mailing Address - Fax:
Practice Address - Street 1:2616 LEGENDS WAY
Practice Address - Street 2:
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017
Practice Address - Country:US
Practice Address - Phone:859-331-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001781A363A00000X
GA008619363A00000X
KYPA1130363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1081470OtherNCCPA