Provider Demographics
NPI:1740453703
Name:ROALSTAD, MELINDA S (PAC)
Entity type:Individual
Prefix:MS
First Name:MELINDA
Middle Name:S
Last Name:ROALSTAD
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 980983
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098
Mailing Address - Country:US
Mailing Address - Phone:435-659-5932
Mailing Address - Fax:435-258-6863
Practice Address - Street 1:1526 WEST UTE BLVD STE 110
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098
Practice Address - Country:US
Practice Address - Phone:435-659-5932
Practice Address - Fax:435-258-6863
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3629561206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant