Provider Demographics
NPI:1316210545
Name:MELLO, PETER RICHARD (PA-C, MPAS)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:RICHARD
Last Name:MELLO
Suffix:
Gender:M
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 WOODLAND RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02770-2224
Mailing Address - Country:US
Mailing Address - Phone:508-954-4749
Mailing Address - Fax:
Practice Address - Street 1:118 DUDLEY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-2403
Practice Address - Country:US
Practice Address - Phone:401-273-4155
Practice Address - Fax:401-273-4155
Is Sole Proprietor?:No
Enumeration Date:2012-02-19
Last Update Date:2012-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00628363AS0400X
MAPA4326363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical