MEDICARE: MELISSA IRENE LIVERMORE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	PA16399	TX

General Provider Information

NPI Number	:	1538877881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA IRENE LIVERMORE PA-C

Provider Business Mailing Address
First Line	:	5000 LEGACY DR STE 200
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75024-3373
Country	:	US
Telephone Number	:	972-494-3100
Fax Number	:

Provider Business Practice Location Address
First Line	:	5000 LEGACY DR STE 215
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75024-3181
Country	:	US
Telephone Number	:	972-494-3100
Fax Number	:	972-608-0005

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2022
Last Update Date	:	04/07/2026

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