Provider Demographics
NPI:1104453638
Name:MODRO, MELISSA KATE (PA-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:KATE
Last Name:MODRO
Suffix:
Gender:F
Credentials:PA-C
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:777 PARK AVE W STE B131A
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-2433
Mailing Address - Country:US
Mailing Address - Phone:847-926-8584
Mailing Address - Fax:847-926-5351
Practice Address - Street 1:777 PARK AVE W STE B131A
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2433
Practice Address - Country:US
Practice Address - Phone:847-926-8584
Practice Address - Fax:847-926-5351
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085007824363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant