Provider Demographics
NPI:1407874480
Name:REITER, MELANIE S (PA)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:S
Last Name:REITER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:S
Other - Last Name:O'BRIEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 80072
Mailing Address - Street 2:
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91716-8072
Mailing Address - Country:US
Mailing Address - Phone:818-340-9988
Mailing Address - Fax:818-587-2493
Practice Address - Street 1:3929 E BELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2112
Practice Address - Country:US
Practice Address - Phone:602-923-5000
Practice Address - Fax:818-587-2493
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1310363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ067620-05Medicaid
AZ067620-05Medicaid
AZ106373Medicare ID - Type Unspecified