Basic Information
| Provider Information | |||||||||
| NPI: | 1811904568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TOMPKINS | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FULLER | ||||||||
| OtherFirstName: | MELISSA | ||||||||
| OtherMiddleName: | L. | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX N | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NE | ||||||||
| PostalCode: | 684460518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4022692011 | ||||||||
| FaxNumber: | 4022692795 | ||||||||
| Practice Location | |||||||||
| Address1: | 2731 HEALTHCARE DR | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NE | ||||||||
| PostalCode: | 684467880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4022692011 | ||||||||
| FaxNumber: | 4022693369 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 03/08/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 960 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 37857 | 01 | NE | BCBS OF NEBRASKA | OTHER |