Healthcare Provider Details

I. General information

NPI: 1093793846
Provider Name (Legal Business Name): MELISSA LYNNE GLASSER-EDWARDS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 11/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E MICHIGAN AVE
GRAYLING MI
49738-7074
US

IV. Provider business mailing address

1250 E MICHIGAN AVE
GRAYLING MI
49738-7074
US

V. Phone/Fax

Practice location:
  • Phone: 989-348-0550
  • Fax: 989-348-0473
Mailing address:
  • Phone: 989-348-0550
  • Fax: 989-348-0473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003707
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: