Provider Demographics
NPI:1477019784
Name:LOO, MELISSA DIANE (PA)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:DIANE
Last Name:LOO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:14044 W CAMELBACK RD STE 204
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-9426
Mailing Address - Country:US
Mailing Address - Phone:623-935-9600
Mailing Address - Fax:623-935-9602
Practice Address - Street 1:14044 W CAMELBACK RD STE 204
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-9426
Practice Address - Country:US
Practice Address - Phone:623-935-9600
Practice Address - Fax:623-935-9602
Is Sole Proprietor?:No
Enumeration Date:2019-02-12
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA9105363A00000X
SC3258363A00000X
AZ8405363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant