Healthcare Provider Details

I. General information

NPI: 1215495635
Provider Name (Legal Business Name): MELISSA J LONDON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2019
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3132 W MARCH LN STE 5
STOCKTON CA
95219-2354
US

IV. Provider business mailing address

3400 DATA DR ATTN CREDENTIALING/PAYER ENROLLMENT
RANCHO CORDOVA CA
95670-7956
US

V. Phone/Fax

Practice location:
  • Phone: 209-475-5500
  • Fax: 209-475-5535
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number58288
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: