Provider Demographics
NPI:1861024606
Name:MOORE, MELANIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:
Last Name:MOORE
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 1:650 GRISWOLD ST
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-1666
Mailing Address - Country:US
Mailing Address - Phone:248-912-0080
Mailing Address - Fax:
Practice Address - Street 1:650 GRISWOLD ST
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1666
Practice Address - Country:US
Practice Address - Phone:734-634-6449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-10
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010239363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty