Provider Demographics
NPI:1265071914
Name:O'BANION, MELISSA ANN
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:O'BANION
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 1:1780 HANSHAW RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-9105
Mailing Address - Country:US
Mailing Address - Phone:607-257-5858
Mailing Address - Fax:
Practice Address - Street 1:1780 HANSHAW RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-9105
Practice Address - Country:US
Practice Address - Phone:607-257-5858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-29
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026223363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program