Provider Demographics
NPI:1073015053
Name:MCRAE, MELINDA
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:MCRAE
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 1:5 TAMPA GENERAL CIR STE 240
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-3578
Mailing Address - Country:US
Mailing Address - Phone:813-258-3309
Mailing Address - Fax:813-251-4454
Practice Address - Street 1:5 TAMPA GENERAL CIR STE 240
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3578
Practice Address - Country:US
Practice Address - Phone:813-258-3309
Practice Address - Fax:813-251-4454
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-06
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9342203367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024169000Medicaid