Provider Demographics
NPI:1942550017
Name:HAAS, MELINDA SUE
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:SUE
Last Name:HAAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 LONG AVE
Mailing Address - Street 2:SUITE NUMBER 110
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-6200
Mailing Address - Country:US
Mailing Address - Phone:716-646-5188
Mailing Address - Fax:
Practice Address - Street 1:17 LONG AVE
Practice Address - Street 2:SUITE NUMBER 110
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-6200
Practice Address - Country:US
Practice Address - Phone:716-646-5188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22616263163WP0200X
390200000X
NY340457363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program