Provider Demographics
NPI:1851023865
Name:MELLON, PARKER (PSS)
Entity Type:Individual
Prefix:
First Name:PARKER
Middle Name:
Last Name:MELLON
Suffix:
Gender:M
Credentials:PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 MADISON ST NE # 222
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-0446
Mailing Address - Country:US
Mailing Address - Phone:503-393-4273
Mailing Address - Fax:
Practice Address - Street 1:2555 SILVERTON RD NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-0837
Practice Address - Country:US
Practice Address - Phone:503-393-4273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000106822175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORTHW000106822OtherOREGON HEALTH AUTHORITY