Provider Demographics
NPI:1730490590
Name:SMALL, MELISSA ANN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:ANN
Last Name:SMALL
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 1:1211 NE 64TH LN UNIT 704
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-6887
Mailing Address - Country:US
Mailing Address - Phone:912-675-5469
Mailing Address - Fax:
Practice Address - Street 1:7421 SW BRIDGEPORT RD STE 220
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7707
Practice Address - Country:US
Practice Address - Phone:503-684-8252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-27
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant