Provider Demographics
NPI:1841210648
Name:FAGEN, MELISSA CHRISTINE (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:CHRISTINE
Last Name:FAGEN
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 1:5058 250TH AVE
Mailing Address - Street 2:
Mailing Address - City:GRANITE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56241-3665
Mailing Address - Country:US
Mailing Address - Phone:320-564-4843
Mailing Address - Fax:
Practice Address - Street 1:1965 FORD PKWY
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-1923
Practice Address - Country:US
Practice Address - Phone:651-696-5509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN893363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant