Provider Demographics
NPI:1053623686
Name:MANZUK, MELISSA (PA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MANZUK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 W WINONA ST APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2673
Mailing Address - Country:US
Mailing Address - Phone:312-218-5456
Mailing Address - Fax:
Practice Address - Street 1:1907 W WINONA ST APT 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2673
Practice Address - Country:US
Practice Address - Phone:312-218-5456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-12
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5334363A00000X
IL085-003751363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant