Provider Demographics
NPI:1104317098
Name:SAN ROMAN, MELISSA E
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:E
Last Name:SAN ROMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 E WICKERSHAM WAY
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7550
Mailing Address - Country:US
Mailing Address - Phone:907-373-7700
Mailing Address - Fax:907-373-1610
Practice Address - Street 1:3600 E WICKERSHAM WAY
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7550
Practice Address - Country:US
Practice Address - Phone:907-373-7700
Practice Address - Fax:907-373-1610
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK130443237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist