Provider Demographics
NPI:1508145582
Name:PEW, MELISSA (PA)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:PEW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 HIGHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6902
Mailing Address - Country:US
Mailing Address - Phone:406-414-5000
Mailing Address - Fax:
Practice Address - Street 1:875 S COTTONWOOD RD STE 200
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-4208
Practice Address - Country:US
Practice Address - Phone:406-414-5336
Practice Address - Fax:406-414-5337
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT78034363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1508145582Medicaid