Provider Demographics
NPI:1851320550
Name:LONNECKER, MELISSA D (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:D
Last Name:LONNECKER
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 1:8899 S 700 E
Mailing Address - Street 2:SUITE 155
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-1810
Mailing Address - Country:US
Mailing Address - Phone:801-413-7775
Mailing Address - Fax:801-878-7507
Practice Address - Street 1:8899 S 700 E
Practice Address - Street 2:SUITE 155
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-1810
Practice Address - Country:US
Practice Address - Phone:801-413-7775
Practice Address - Fax:801-878-7507
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4977471-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP56498Medicare UPIN