Provider Demographics
NPI:1285770719
Name:MARINO, MELISSA ANNE (PA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANNE
Last Name:MARINO
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 1:2100 POWELL ST STE 900
Mailing Address - Street 2:CEP - MEDAMERICA - CREDENTIALING DEPT.
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1844
Mailing Address - Country:US
Mailing Address - Phone:510-350-2664
Mailing Address - Fax:
Practice Address - Street 1:2100 POWELL ST STE 900
Practice Address - Street 2:CEP - MEDAMERICA - CREDENTIALING DEPT.
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-1844
Practice Address - Country:US
Practice Address - Phone:510-350-2664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17309363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17309OtherPHYSICIAN'S ASSISTANT