Provider Demographics
NPI:1962618819
Name:LAKE, MELANIE J (PA)
Entity type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:J
Last Name:LAKE
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:848 STATE ROUTE 50
Mailing Address - Street 2:
Mailing Address - City:BURNT HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:12027-9511
Mailing Address - Country:US
Mailing Address - Phone:518-831-1500
Mailing Address - Fax:518-377-1677
Practice Address - Street 1:848 STATE ROUTE 50
Practice Address - Street 2:
Practice Address - City:BURNT HILLS
Practice Address - State:NY
Practice Address - Zip Code:12027-9511
Practice Address - Country:US
Practice Address - Phone:518-831-1500
Practice Address - Fax:518-377-1677
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2025-02-13
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Provider Licenses
StateLicense IDTaxonomies
NY007368363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02054451Medicaid