Healthcare Provider Details

I. General information

NPI: 1790518710
Provider Name (Legal Business Name): MELISSA SUAREZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MELISSA SERRATO

II. Dates (important events)

Enumeration Date: 08/23/2024
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

299 S MAIN ST SUITE 1300 PMB 94922
SALT LAKE CITY UT
84111
US

IV. Provider business mailing address

299 S MAIN ST SUITE 1300 PMB 94922
SALT LAKE CITY UT
84111
US

V. Phone/Fax

Practice location:
  • Phone: 385-202-3140
  • Fax:
Mailing address:
  • Phone: 385-202-3140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: