Basic Information
| Provider Information | |||||||||
| NPI: | 1578544110 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DURHAM | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1222 TROTWOOD AVE | ||||||||
| Address2: | SUITE 211 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384016436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313803033 | ||||||||
| FaxNumber: | 9313883401 | ||||||||
| Practice Location | |||||||||
| Address1: | 1222 TROTWOOD AVE | ||||||||
| Address2: | SUITE 211 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384016436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313803033 | ||||||||
| FaxNumber: | 9313883401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 01/15/2010 | ||||||||
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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 | 363AS0400X | 992 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 3669739 | 05 | TN | MEDICAID |