Provider Demographics
NPI:1972823110
Name:HENDRICKSON, MELISSA T (PA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:T
Last Name:HENDRICKSON
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 1:2837 US 41 W
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2252
Mailing Address - Country:US
Mailing Address - Phone:906-225-3964
Mailing Address - Fax:906-226-3875
Practice Address - Street 1:580 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2705
Practice Address - Country:US
Practice Address - Phone:906-225-7808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003620363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant