Provider Demographics
NPI:1508876483
Name:PENG, MELISSA D (PA)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:D
Last Name:PENG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:MELISSA
Other - Middle Name:D
Other - Last Name:CROSS-PENG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:9735 SW SHADY LN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5481
Mailing Address - Country:US
Mailing Address - Phone:503-639-2800
Mailing Address - Fax:503-639-4044
Practice Address - Street 1:9735 SW SHADY LN
Practice Address - Street 2:SUTIE 100
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-5481
Practice Address - Country:US
Practice Address - Phone:503-639-2800
Practice Address - Fax:503-639-4044
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00703363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant