MEDICARE: MELISSA NIEMIEC

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	390200000X	Student in an Organized Health Care Education/Training Program
2	363AM0700X	Medical Physician Assistant	PA222339	OR

General Provider Information

NPI Number	:	1861113961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA NIEMIEC

Provider Business Mailing Address
First Line	:	3303 S BOND AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97239-4501
Country	:	US
Telephone Number	:	503-346-1500
Fax Number	:

Provider Business Practice Location Address
First Line	:	1300 YALE PL APT 314
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-2160
Country	:	US
Telephone Number	:	630-877-3947
Fax Number	:

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

Provider Enumeration Date	:	09/07/2022
Last Update Date	:	01/17/2025

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Directions to “ MELISSA NIEMIEC ” Practice Location

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