Healthcare Provider Details

I. General information

NPI: 1649463118
Provider Name (Legal Business Name): MELISSA PENDERGRASS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2007
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19875 SW 65TH AVE STE 250
TUALATIN OR
97062-8353
US

IV. Provider business mailing address

19875 SW 65TH AVE STE 250
TUALATIN OR
97062-8353
US

V. Phone/Fax

Practice location:
  • Phone: 503-612-5260
  • Fax:
Mailing address:
  • Phone: 503-612-5260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282NW0100X
TaxonomyWomen's Hospital
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number125-053708
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: