Basic Information
Provider Information
NPI: 1003291246
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PEARSON
FirstName: MELISSA
MiddleName: NICHO
NamePrefix:  
NameSuffix:  
Credential: PA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2701 SUNSET RIDGE DR STE 200
Address2:  
City: ROCKWALL
State: TX
PostalCode: 750320007
CountryCode: US
TelephoneNumber: 9727725450
FaxNumber: 9727725452
Practice Location
Address1: 2701 SUNSET RIDGE DR STE 200
Address2:  
City: ROCKWALL
State: TX
PostalCode: 750320007
CountryCode: US
TelephoneNumber: 9727725450
FaxNumber: 9727725452
Other Information
ProviderEnumerationDate: 07/29/2015
LastUpdateDate: 05/13/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363A00000XPA09939TXY Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 

No ID Information.


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