Provider Demographics
NPI:1356440085
Name:TSOMIDES, MELISSA L (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
Last Name:TSOMIDES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 FORE RIVER PARKWAY
Mailing Address - Street 2:SUITE 420
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102
Mailing Address - Country:US
Mailing Address - Phone:207-878-3177
Mailing Address - Fax:207-878-2156
Practice Address - Street 1:195 FORE RIVER PARKWAY
Practice Address - Street 2:SUITE 420
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102
Practice Address - Country:US
Practice Address - Phone:207-878-3177
Practice Address - Fax:207-878-2156
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA001062363AM0700X
MEPA-191363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM4530Medicare PIN
Q21929Medicare UPIN