Basic Information
| Provider Information | |||||||||
| NPI: | 1114294378 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QUITAYEN | ||||||||
| FirstName: | MELBA | ||||||||
| MiddleName: | GUSSY C | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | NASHUA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030603924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038831626 | ||||||||
| FaxNumber: | 6038819914 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 PROSPECT ST | ||||||||
| Address2: | |||||||||
| City: | NASHUA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030603924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6038831626 | ||||||||
| FaxNumber: | 6038819914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2011 | ||||||||
| LastUpdateDate: | 07/05/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0862 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 3074422 | 05 | NH | MEDICAID |