Healthcare Provider Details

I. General information

NPI: 1144748401
Provider Name (Legal Business Name): MELISSA BROOKE HASTINGS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA NEWPORT

II. Dates (important events)

Enumeration Date: 09/06/2017
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8118 GOOD LUCK RD
LANHAM MD
20706-3574
US

IV. Provider business mailing address

5000 COX RD
GLEN ALLEN VA
23060-9263
US

V. Phone/Fax

Practice location:
  • Phone: 240-686-2300
  • Fax:
Mailing address:
  • Phone: 804-968-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC06506
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: