Provider Demographics
NPI:1972584209
Name:FORTNER, MELISSA JOYANN (PAC)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:JOYANN
Last Name:FORTNER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:JOYANN
Other - Last Name:WILENSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4290 POLK AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-1524
Mailing Address - Country:US
Mailing Address - Phone:619-563-0507
Mailing Address - Fax:619-563-0015
Practice Address - Street 1:4290 POLK AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1524
Practice Address - Country:US
Practice Address - Phone:619-563-0507
Practice Address - Fax:619-563-0015
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15119363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P60482Medicare UPIN