Provider Demographics
NPI:1144520453
Name:BARONE, MELISSA BROOKE (PA-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:BROOKE
Last Name:BARONE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:
Other - Last Name:BARONE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:975 SE SANDY BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1308
Mailing Address - Country:US
Mailing Address - Phone:503-236-0775
Mailing Address - Fax:503-236-0786
Practice Address - Street 1:875 OAK ST SE
Practice Address - Street 2:SUITE 5020
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3975
Practice Address - Country:US
Practice Address - Phone:503-371-4044
Practice Address - Fax:503-371-4356
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA152631363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1144520453Medicaid
OR500633281Medicaid
OR159092Medicare PIN