Provider Demographics
NPI:1174756977
Name:FERGUSON, MELISSA (PAC)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:FROEHLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:400 EAST MAIN STREET
Mailing Address - Street 2:EMERGENCY DEPARTMEN
Mailing Address - City:MT KISCO
Mailing Address - State:NY
Mailing Address - Zip Code:10549
Mailing Address - Country:US
Mailing Address - Phone:914-666-1254
Mailing Address - Fax:
Practice Address - Street 1:400 EAST MAIN STREET
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:MT KISCO
Practice Address - State:NY
Practice Address - Zip Code:10549
Practice Address - Country:US
Practice Address - Phone:203-852-2281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-26
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2297363A00000X
NY23 013454363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant