Provider Demographics
NPI:1215911599
Name:THOMPSON, MELISSA R (PA)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:R
Last Name:THOMPSON
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:PO BOX 22075
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97269-2075
Mailing Address - Country:US
Mailing Address - Phone:503-659-4777
Mailing Address - Fax:503-652-5223
Practice Address - Street 1:10024 SE 32ND AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6514
Practice Address - Country:US
Practice Address - Phone:503-659-4988
Practice Address - Fax:503-654-5666
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00815363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR970025914OtherRR MEDICARE
OR077599Medicaid
ORP62040Medicare UPIN
OR113354Medicare ID - Type UnspecifiedMEDICARE