Healthcare Provider Details

I. General information

NPI: 1669097630
Provider Name (Legal Business Name): MELITZA MEJIA-CENTENO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 S CHIPETA WAY STE A
SALT LAKE CITY UT
84108-1261
US

IV. Provider business mailing address

1652 W 800 S
SALT LAKE CITY UT
84104-3112
US

V. Phone/Fax

Practice location:
  • Phone: 801-585-0187
  • Fax:
Mailing address:
  • Phone: 623-205-5972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA68368
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: