Provider Demographics
NPI:1851481725
Name:MOORE, MELISSA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:MARIE
Last Name:MOORE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2570 NW EDENBOWER BLVD
Mailing Address - Street 2:#100
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471
Mailing Address - Country:US
Mailing Address - Phone:541-677-7200
Mailing Address - Fax:541-229-3309
Practice Address - Street 1:2570 NW EDENBOWER BLVD
Practice Address - Street 2:#100
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471
Practice Address - Country:US
Practice Address - Phone:541-677-7200
Practice Address - Fax:541-229-3309
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL85002846363AM0700X
ORPA03176363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical