Provider Demographics
NPI:1881148419
Name:PELOSI, MELISSA RAE (PA)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:RAE
Last Name:PELOSI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SE 8TH AVE APT 680
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-3885
Mailing Address - Country:US
Mailing Address - Phone:561-251-7610
Mailing Address - Fax:
Practice Address - Street 1:9035 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024
Practice Address - Country:US
Practice Address - Phone:954-378-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-11
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109769363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1881148419OtherNPI