Provider Demographics
NPI:1104139823
Name:RUSSELL, MELISSA D (PA-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:D
Last Name:RUSSELL
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 1:203 N WASHINGTON ST STE 300
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-0233
Mailing Address - Country:US
Mailing Address - Phone:509-444-8888
Mailing Address - Fax:509-444-7806
Practice Address - Street 1:3919 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-1349
Practice Address - Country:US
Practice Address - Phone:509-444-7801
Practice Address - Fax:509-444-7807
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-22
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAPA60157507363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical