Basic Information
| Provider Information | |||||||||
| NPI: | 1336121433 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELVIN | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7648 | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420027648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705753113 | ||||||||
| FaxNumber: | 2705753135 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 KENTUCKY AVE | ||||||||
| Address2: | STE 301 | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420033817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2705753113 | ||||||||
| FaxNumber: | 2705753135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 03/25/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA802 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 9500390100 | 05 | KY | MEDICAID | 000000512695 | 01 | ANTHEM | OTHER | 862893 | 01 | HEALTHLINK | OTHER |