Basic Information
| Provider Information | |||||||||
| NPI: | 1417030164 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JONES | ||||||||
| FirstName: | MELORA | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | P.A-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2450 W HUNTING PARK AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191291302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157075030 | ||||||||
| FaxNumber: | 2157073494 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 N BROAD ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191405103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157075030 | ||||||||
| FaxNumber: | 2157073494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 04/24/2018 | ||||||||
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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 | MA052742 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | CD4829 | 01 | PA | RR MEDICARE GROUP TPI | OTHER | 100727800 | 01 | PA | MEDICAID GROUP TPI | OTHER | 597586 | 01 | PA | MEDICARE GROUP TPI | OTHER | 1417030164 | 05 | PA | MEDICAID |