Healthcare Provider Details

I. General information

NPI: 1154627362
Provider Name (Legal Business Name): AMAIYA MELISSA THOMPSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMAIYA MELISSA JACKSON PA-C

II. Dates (important events)

Enumeration Date: 02/04/2011
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8767 WILSHIRE BLVD FL 2
BEVERLY HILLS CA
90211-2714
US

IV. Provider business mailing address

1820 W ORANGEWOOD AVE STE 105
ORANGE CA
92868-5052
US

V. Phone/Fax

Practice location:
  • Phone: 310-248-7000
  • Fax: 310-248-7033
Mailing address:
  • Phone: 703-310-9495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA58134
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number58134
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: