Healthcare Provider Details

I. General information

NPI: 1477019784
Provider Name (Legal Business Name): MELISSA DIANE LOO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 08/05/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14044 W CAMELBACK RD STE 204
LITCHFIELD PARK AZ
85340-9426
US

IV. Provider business mailing address

14044 W CAMELBACK RD STE 204
LITCHFIELD PARK AZ
85340-9426
US

V. Phone/Fax

Practice location:
  • Phone: 623-935-9600
  • Fax: 623-935-9602
Mailing address:
  • Phone: 623-935-9600
  • Fax: 623-935-9602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9105
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3258
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8405
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: