Provider Demographics
NPI:1992959522
Name:LUDWIG, MELISSA HEIDI (PA-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:HEIDI
Last Name:LUDWIG
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 1:380 N 200 W
Mailing Address - Street 2:SUITE 209
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7079
Mailing Address - Country:US
Mailing Address - Phone:801-298-1300
Mailing Address - Fax:801-296-6199
Practice Address - Street 1:380 N 200 W
Practice Address - Street 2:SUITE 209
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7079
Practice Address - Country:US
Practice Address - Phone:801-298-1300
Practice Address - Fax:801-296-6199
Is Sole Proprietor?:No
Enumeration Date:2008-11-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4797308-1206363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP00662902OtherRR MEDICARE
UTP00662902OtherRR MEDICARE