Healthcare Provider Details

I. General information

NPI: 1225136542
Provider Name (Legal Business Name): MELANIE CHISAM P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 12/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 S NATIONAL AVE STE 510
SPRINGFIELD MO
65807-5284
US

IV. Provider business mailing address

PO BOX 9007
SPRINGFIELD MO
65808-9007
US

V. Phone/Fax

Practice location:
  • Phone: 417-875-3114
  • Fax:
Mailing address:
  • Phone: 417-875-3462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2005007764
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: