Provider Demographics
NPI:1124008602
Name:PORTER, MELISSA HOPE (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:HOPE
Last Name:PORTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 GORDON AVE
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-6613
Mailing Address - Country:US
Mailing Address - Phone:229-226-0125
Mailing Address - Fax:229-226-0195
Practice Address - Street 1:900 GORDON AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6613
Practice Address - Country:US
Practice Address - Phone:229-226-0125
Practice Address - Fax:229-226-0195
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113435363A00000X
GA3765363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100001756BMedicaid
GA376752OtherWELLCARE
GAP00276196OtherRAILROAD MEDICARE
GA100001756BOtherPEACH STATE
GA100001456CMedicaid
GA97WCHCXMedicare PIN
GAP42164Medicare UPIN
GA376752OtherWELLCARE
GA100001456CMedicaid