Healthcare Provider Details

I. General information

NPI: 1114673175
Provider Name (Legal Business Name): MELISSA SALISBURY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2022
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CENTRAL AVE SE
ALBUQUERQUE NM
87106-4934
US

IV. Provider business mailing address

44 WIND RD NW
ALBUQUERQUE NM
87120-1914
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-1234
  • Fax:
Mailing address:
  • Phone: 616-915-1401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: