Basic Information
| Provider Information | |||||||||
| NPI: | 1104290634 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEITZ | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | CLARE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DANKBAR | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | CLARE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2550 UNIVERSITY AVE W STE 110N | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551142001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516025311 | ||||||||
| FaxNumber: | 6512226786 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 E 26TH ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554044552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128846300 | ||||||||
| FaxNumber: | 6128846363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2015 | ||||||||
| LastUpdateDate: | 10/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 11936 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.