Basic Information
| Provider Information | |||||||||
| NPI: | 1629216288 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELENDEZ-CORTEZ | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 MARTIN LUTHER KING JR WAY | ||||||||
| Address2: | PO BOX 5299 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534037537 | ||||||||
| FaxNumber: | 2534037539 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 MARTIN LUTHER KING JR WAY | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534037537 | ||||||||
| FaxNumber: | 2534037539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2009 | ||||||||
| LastUpdateDate: | 11/26/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA60063828 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA60063828 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | MM1911191 | 01 | WA | DEA | OTHER |