Provider Demographics
NPI:1801079231
Name:CHRISTENSEN, MELISSA M (PA-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
Last Name:CHRISTENSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:M
Other - Last Name:LOUGHEED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2400 32ND AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-5800
Mailing Address - Country:US
Mailing Address - Phone:701-234-2829
Mailing Address - Fax:701-234-3868
Practice Address - Street 1:2400 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-5800
Practice Address - Country:US
Practice Address - Phone:701-234-2829
Practice Address - Fax:701-234-3868
Is Sole Proprietor?:No
Enumeration Date:2007-12-07
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0382363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDN716448Medicare PIN
NDN713237Medicare PIN