Provider Demographics
NPI:1306837109
Name:TIEDEMANN, MELISSA JANE (RPA-C)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:JANE
Last Name:TIEDEMANN
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2800 MARCUS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1113
Mailing Address - Country:US
Mailing Address - Phone:516-622-6000
Mailing Address - Fax:
Practice Address - Street 1:2750 MERRICK RD
Practice Address - Street 2:
Practice Address - City:BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-5720
Practice Address - Country:US
Practice Address - Phone:516-409-2000
Practice Address - Fax:516-409-2720
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008301363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4F9741Medicare ID - Type Unspecified
NYP45281Medicare UPIN