Basic Information
| Provider Information | |||||||||
| NPI: | 1730490590 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMALL | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1211 NE 64TH LN UNIT 704 | ||||||||
| Address2: | |||||||||
| City: | HILLSBORO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971246887 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126755469 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7421 SW BRIDGEPORT RD STE 220 | ||||||||
| Address2: | |||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972247707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036848252 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2010 | ||||||||
| LastUpdateDate: | 12/31/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.