Provider Demographics
NPI:1881788180
Name:HERTLER, MELISSA AM (MD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:AM
Last Name:HERTLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:MARQUARDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15 SHRINE CLUB RD STE B
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-8502
Mailing Address - Country:US
Mailing Address - Phone:307-206-1440
Mailing Address - Fax:307-206-1444
Practice Address - Street 1:15 SHRINE CLUB RD
Practice Address - Street 2:STE B
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-8502
Practice Address - Country:US
Practice Address - Phone:307-332-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51837-20207Y00000X
WYTL4446207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI68015-0101Medicare PIN
WI02120-0305Medicare PIN