MEDICARE: LISA MELNIK PEARSON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	3649	CT
2	363AS0400X	Surgical Physician Assistant	013905	NY
3	363AS0400X	Surgical Physician Assistant	3649	CT

General Provider Information

NPI Number	:	1497928931
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MELNIK PEARSON PA-C

Provider Business Mailing Address
First Line	:	PO BOX 29234
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10087-9234
Country	:	US
Telephone Number	:	203-705-0715
Fax Number	:	203-705-0717

Provider Business Practice Location Address
First Line	:	1 BLACHLEY RD
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06902-0002
Country	:	US
Telephone Number	:	203-705-0715
Fax Number	:	203-705-0717

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/04/2008
Last Update Date	:	10/12/2022

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