Healthcare Provider Details

I. General information

NPI: 1376926055
Provider Name (Legal Business Name): JUSTIN MELLO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JUSTIN MELLO PA

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

15 LA SALLE SQ
PROVIDENCE RI
02903-1814
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-4000
  • Fax:
Mailing address:
  • Phone: 401-444-6779
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0004326
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01914
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: