Basic Information
| Provider Information | |||||||||
| NPI: | 1376513564 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELVIN | ||||||||
| FirstName: | TABITHA | ||||||||
| MiddleName: | SUE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1450 COLUMBUS AVE STE 104 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON COURT HOUSE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431603701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403332236 | ||||||||
| FaxNumber: | 7403333881 | ||||||||
| Practice Location | |||||||||
| Address1: | 1510 COLUMBUS AVE STE 230 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON COURT HOUSE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431601987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403333333 | ||||||||
| FaxNumber: | 7403335171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 10/23/2013 | ||||||||
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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 | 363AM0700X | 50001977 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 0068840 | 05 | OH | MEDICAID |