Provider Demographics
NPI:1912952003
Name:GANTNER, MELANIE (PA)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:GANTNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 WALTON BLVD
Mailing Address - Street 2:STE C
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-8433
Mailing Address - Country:US
Mailing Address - Phone:575-525-2700
Mailing Address - Fax:575-524-2045
Practice Address - Street 1:540 WALTON BLVD
Practice Address - Street 2:STE C
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-8433
Practice Address - Country:US
Practice Address - Phone:575-525-2700
Practice Address - Fax:575-524-2045
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2004-0012363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical