Healthcare Provider Details

I. General information

NPI: 1104750769
Provider Name (Legal Business Name): MELISSA A SHORT RRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 PROSPECT AVE
SYRACUSE NY
13203-1899
US

IV. Provider business mailing address

11333 DUANESBURG RD
DELANSON NY
12053-2627
US

V. Phone/Fax

Practice location:
  • Phone: 315-448-5771
  • Fax: 315-448-5296
Mailing address:
  • Phone: 518-657-1768
  • Fax: 315-448-5296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License Number000277
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: