Basic Information
| Provider Information | |||||||||
| NPI: | 1689905689 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALL | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EDSON | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | K | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2725 S 144TH ST | ||||||||
| Address2: | #110 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681445243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4026370400 | ||||||||
| FaxNumber: | 4026370401 | ||||||||
| Practice Location | |||||||||
| Address1: | 2725 S 144TH ST | ||||||||
| Address2: | #110 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681445243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4026370400 | ||||||||
| FaxNumber: | 4026370401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2010 | ||||||||
| LastUpdateDate: | 12/06/2012 | ||||||||
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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 | 1484 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.