Provider Demographics
NPI:1033122031
Name:MELKER, CLINO M
Entity Type:Individual
Prefix:
First Name:CLINO
Middle Name:M
Last Name:MELKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1450
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70069-1450
Mailing Address - Country:US
Mailing Address - Phone:985-651-9293
Mailing Address - Fax:
Practice Address - Street 1:148 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:LA PLACE
Practice Address - State:LA
Practice Address - Zip Code:70068-5939
Practice Address - Country:US
Practice Address - Phone:985-651-9293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN043269367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1687413Medicaid
LA5X079Medicare PIN