Provider Demographics
NPI:1639799265
Name:LACAYO, MELISSA ANDREA JIMENEZ (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANDREA JIMENEZ
Last Name:LACAYO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40401
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90239-1401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5101 FLORENCE AVE STE 4
Practice Address - Street 2:
Practice Address - City:BELL
Practice Address - State:CA
Practice Address - Zip Code:90201-3801
Practice Address - Country:US
Practice Address - Phone:323-560-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-23
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA58046363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant