Provider Demographics
NPI:1467868638
Name:OTHMER, MELISSA JENNY (PA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:JENNY
Last Name:OTHMER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:J
Other - Last Name:ALWARDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:600 GRESHAM DR STE 8620
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1904
Mailing Address - Country:US
Mailing Address - Phone:757-395-1600
Mailing Address - Fax:757-625-0433
Practice Address - Street 1:600 GRESHAM DR STE 8620
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-395-1600
Practice Address - Fax:757-625-0433
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017686363AM0700X
VA0110004967363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical