Provider Demographics
NPI:1083691059
Name:MEYER, MELISSA AYN (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:AYN
Last Name:MEYER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 BEACH DR E
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-4937
Mailing Address - Country:US
Mailing Address - Phone:360-895-4680
Mailing Address - Fax:360-895-4709
Practice Address - Street 1:1141 BEACH DR E
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-4937
Practice Address - Country:US
Practice Address - Phone:360-895-4680
Practice Address - Fax:360-895-4709
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00048156207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN