Provider Demographics
NPI:1265701015
Name:MOLLIGAN, MELANIE WENDT (PA-C)
Entity type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:WENDT
Last Name:MOLLIGAN
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:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-7770
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13330 USF LAUREL DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-6601
Practice Address - Country:US
Practice Address - Phone:813-974-2201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-23
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106274363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010519400Medicaid
FLY0AR5OtherBLUE CROSS BLUE SHIELD
FLP01439989Medicare PIN
FLFT660XMedicare PIN