Provider Demographics
NPI:1124837257
Name:TAKUBO, MELANIE BAGSHAW (PA-C)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:BAGSHAW
Last Name:TAKUBO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 ANGEL TER
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-2116
Mailing Address - Country:US
Mailing Address - Phone:304-989-5858
Mailing Address - Fax:
Practice Address - Street 1:3100 MACCORKLE AVE SE STE 902
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1234
Practice Address - Country:US
Practice Address - Phone:304-388-6590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-03
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV842363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant