Provider Demographics
NPI:1184881898
Name:POTACZEK, MELANIE LYNN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:LYNN
Last Name:POTACZEK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:MELANIE
Other - Middle Name:LYNN
Other - Last Name:CRNIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-1510
Mailing Address - Country:US
Mailing Address - Phone:715-838-5895
Mailing Address - Fax:
Practice Address - Street 1:1222 E WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:BARRON
Practice Address - State:WI
Practice Address - Zip Code:54812-1765
Practice Address - Country:US
Practice Address - Phone:715-838-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2333-023363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical