Provider Demographics
NPI:1881672517
Name:MILLARE, MELODEE LUBAG (PA)
Entity Type:Individual
Prefix:
First Name:MELODEE
Middle Name:LUBAG
Last Name:MILLARE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10326 TANK HOUSE DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-4337
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:73 W MARCH LN
Practice Address - Street 2:SUITE A
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5726
Practice Address - Country:US
Practice Address - Phone:209-957-5888
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17732363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical