Healthcare Provider Details

I. General information

NPI: 1992369276
Provider Name (Legal Business Name): MELLISSA RUIZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2019
Last Update Date: 05/03/2024
Certification Date: 05/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39TH MEDICAL GROUP, UNIT 7095
APO AE
09824
UM

IV. Provider business mailing address

39TH MEDICAL GROUP, UNIT 7095
APO AE
09824
UM

V. Phone/Fax

Practice location:
  • Phone: 520-228-2778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: