Provider Demographics
NPI:1396733671
Name:KIROUAC, MELANIE J (PA)
Entity type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:J
Last Name:KIROUAC
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:MELANIE
Other - Middle Name:J
Other - Last Name:KRUPA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:200 SEABURY DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-5618
Mailing Address - Country:US
Mailing Address - Phone:860-785-5238
Mailing Address - Fax:
Practice Address - Street 1:759 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1619
Practice Address - Country:US
Practice Address - Phone:413-794-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA1772363AS0400X, 363AM0700X
CT5778363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP2074Medicare PIN
Q18688Medicare UPIN