Basic Information
Provider Information | |||||||||
NPI: | 1790787356 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROHRER | ||||||||
FirstName: | MELISSA | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 659 HIGHLAND AVE | ||||||||
Address2: |   | ||||||||
City: | GLEN ELLYN | ||||||||
State: | IL | ||||||||
PostalCode: | 601374019 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6304749254 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 603 E PINE ST | ||||||||
Address2: |   | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741064849 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9185872171 | ||||||||
FaxNumber: | 9182956155 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/12/2005 | ||||||||
LastUpdateDate: | 07/20/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085002573 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 200007950B | 05 | OK |   | MEDICAID |