Basic Information
Provider Information | |||||||||
NPI: | 1386676039 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PARK | ||||||||
FirstName: | MELISSA | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BROOMHALL | ||||||||
OtherFirstName: | MELISSA | ||||||||
OtherMiddleName: | LEE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 611 N IRON BRIDGE WAY | ||||||||
Address2: |   | ||||||||
City: | SPOKANE | ||||||||
State: | WA | ||||||||
PostalCode: | 992024932 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5094448888 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1203 IDAHO ST | ||||||||
Address2: |   | ||||||||
City: | LEWISTON | ||||||||
State: | ID | ||||||||
PostalCode: | 835011940 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5094448888 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2006 | ||||||||
LastUpdateDate: | 07/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 015943 | ME | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | M-10546 | ID | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 431898000 | 05 | ME |   | MEDICAID | 808286200 | 05 | ID |   | MEDICAID |