Provider Demographics
NPI:1235741802
Name:MATEO, MELISSA TROI (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:TROI
Last Name:MATEO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:TROI
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1515 E COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-1846
Mailing Address - Country:US
Mailing Address - Phone:509-488-5256
Mailing Address - Fax:509-488-9939
Practice Address - Street 1:1515 E COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-1846
Practice Address - Country:US
Practice Address - Phone:509-488-5256
Practice Address - Fax:509-488-9939
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61222414363A00000X, 363AM0700X
WAPA61157642363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPA61222414OtherDOH LICENSE