MEDICARE: MRS. MELISSA D PENG PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA00703	OR

General Provider Information

NPI Number	:	1508876483
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MELISSA D PENG PA

Provider Business Mailing Address
First Line	:	9735 SW SHADY LN
Second Line	:	SUITE 100
City	:	TIGARD
State	:	OR
Zip	:	97223-5481
Country	:	US
Telephone Number	:	503-639-2800
Fax Number	:	503-639-4044

Provider Business Practice Location Address
First Line	:	9735 SW SHADY LN
Second Line	:	SUTIE 100
City	:	TIGARD
State	:	OR
Zip	:	97223-5481
Country	:	US
Telephone Number	:	503-639-2800
Fax Number	:	503-639-4044

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	06/21/2021

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