Provider Demographics
NPI:1588675250
Name:GAMBLE, MELISSA L (PAC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
Last Name:GAMBLE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 COLLEGE ST SE
Mailing Address - Street 2:PMG SW WA LACEY FM
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503
Mailing Address - Country:US
Mailing Address - Phone:360-486-2900
Mailing Address - Fax:360-486-2901
Practice Address - Street 1:1802 S UNION AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405
Practice Address - Country:US
Practice Address - Phone:253-752-6965
Practice Address - Fax:253-759-6056
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004887363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0207064OtherLABOR & INDUSTRIES
WA1820GAOtherREGENEE BC BS
WA8448573Medicaid
WA8448573Medicaid
WA8859542Medicare ID - Type Unspecified