Healthcare Provider Details

I. General information

NPI: 1821694464
Provider Name (Legal Business Name): MELISSA GRACE WASIELEWSKI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2020
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 SCRANTON CARBONDALE HWY
SCRANTON PA
18508-1115
US

IV. Provider business mailing address

449 SCRANTON CARBONDALE HWY
SCRANTON PA
18508-1115
US

V. Phone/Fax

Practice location:
  • Phone: 570-344-6000
  • Fax: 570-344-6002
Mailing address:
  • Phone: 570-344-6000
  • Fax: 570-344-6002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA062163
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: