Provider Demographics
NPI:1740235803
Name:BOTELLO, MELISSA G (PAC)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:G
Last Name:BOTELLO
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 1:605 N MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:DONNA
Mailing Address - State:TX
Mailing Address - Zip Code:78537-2726
Mailing Address - Country:US
Mailing Address - Phone:956-464-4407
Mailing Address - Fax:956-464-4426
Practice Address - Street 1:605 N MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:DONNA
Practice Address - State:TX
Practice Address - Zip Code:78537-2726
Practice Address - Country:US
Practice Address - Phone:956-464-4407
Practice Address - Fax:956-464-4426
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA04207363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA04207OtherTEXAS STATE LIC.
TX8L15326Medicare PIN
TX613536/GROUP PTANMedicare PIN