Healthcare Provider Details

I. General information

NPI: 1871258004
Provider Name (Legal Business Name): MELISSA ANNE STASIAK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2021
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 211699
EAGAN MN
55121-3699
US

IV. Provider business mailing address

PO BOX 211699
EAGAN MN
55121-3699
US

V. Phone/Fax

Practice location:
  • Phone: 866-849-0692
  • Fax: 888-973-8821
Mailing address:
  • Phone: 866-849-0692
  • Fax: 888-973-8821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number334137
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: