Healthcare Provider Details

I. General information

NPI: 1700982766
Provider Name (Legal Business Name): MELISSA K DVORAK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 11/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6405 FRANCE AVE S SUITE W440
EDINA MN
55435-2163
US

IV. Provider business mailing address

3400 W 66TH ST SUITE 350
EDINA MN
55435-2111
US

V. Phone/Fax

Practice location:
  • Phone: 952-927-7004
  • Fax: 952-927-5146
Mailing address:
  • Phone: 952-832-0805
  • Fax: 952-832-5597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number10187
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: