Healthcare Provider Details

I. General information

NPI: 1750838413
Provider Name (Legal Business Name): KRISTIAN ANDREAS MELBY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

442 CROCKER ST
LOS ANGELES CA
90013-2115
US

IV. Provider business mailing address

442 CROCKER ST
LOS ANGELES CA
90013-2115
US

V. Phone/Fax

Practice location:
  • Phone: 323-201-4516
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA57172
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: