Provider Demographics
NPI:1902871759
Name:WATERMAN-KEINATH, MELISSA ANN (PA-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:WATERMAN-KEINATH
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 1:6525 BARRIE RD
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2305
Mailing Address - Country:US
Mailing Address - Phone:952-915-6000
Mailing Address - Fax:952-915-6100
Practice Address - Street 1:6525 BARRIE RD
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2305
Practice Address - Country:US
Practice Address - Phone:952-915-6000
Practice Address - Fax:952-915-6100
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9373363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNS69698Medicare UPIN