Provider Demographics
NPI:1225668205
Name:REAGAN, MELISSA HISAKO
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:HISAKO
Last Name:REAGAN
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 1:207 BRIDGEWATER CIR
Mailing Address - Street 2:
Mailing Address - City:SUISUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94585-1774
Mailing Address - Country:US
Mailing Address - Phone:707-389-6421
Mailing Address - Fax:
Practice Address - Street 1:1261 TRAVIS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-4804
Practice Address - Country:US
Practice Address - Phone:707-422-0543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-18
Last Update Date:2020-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAZ9T4J4S3363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9885321OtherKAISER