Healthcare Provider Details

I. General information

NPI: 1235741802
Provider Name (Legal Business Name): MELISSA TROI MATEO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MELISSA TROI KELLER

II. Dates (important events)

Enumeration Date: 08/17/2020
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 E COLUMBIA ST
OTHELLO WA
99344-1846
US

IV. Provider business mailing address

1515 E COLUMBIA ST
OTHELLO WA
99344-1846
US

V. Phone/Fax

Practice location:
  • Phone: 509-488-5256
  • Fax: 509-488-9939
Mailing address:
  • Phone: 509-488-5256
  • Fax: 509-488-9939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61222414
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA61157642
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA61222414
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: