Basic Information
| Provider Information | |||||||||
| NPI: | 1992959522 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUDWIG | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | HEIDI | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 380 N 200 W | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840107079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012981300 | ||||||||
| FaxNumber: | 8012966199 | ||||||||
| Practice Location | |||||||||
| Address1: | 380 N 200 W | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | BOUNTIFUL | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840107079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012981300 | ||||||||
| FaxNumber: | 8012966199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2008 | ||||||||
| LastUpdateDate: | 03/10/2010 | ||||||||
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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 | 4797308-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 4797308-1206 | UT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | P00662902 | 01 | UT | RR MEDICARE | OTHER |