Provider Demographics
NPI:1699737676
Name:KENT, MELISSA S (PA-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:S
Last Name:KENT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:S
Other - Last Name:KENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1400 N JOHNSON AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-1651
Mailing Address - Country:US
Mailing Address - Phone:619-442-0277
Mailing Address - Fax:
Practice Address - Street 1:1400 N JOHNSON AVE STE 101
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-1651
Practice Address - Country:US
Practice Address - Phone:619-442-0277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53433363A00000X, 363A00000X
CAPA53433363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200974500AMedicaid
WY1699737676Medicaid
CO82587841Medicaid
WY1699737676Medicaid
CO82587841Medicaid
COCOAAA3775Medicare PIN
CO523088Medicare PIN
KS200974500AMedicaid