Provider Demographics
NPI:1144379348
Name:HURSTON, MELANIE A (PA)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:A
Last Name:HURSTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:A
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 231509
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36123-1509
Mailing Address - Country:US
Mailing Address - Phone:334-396-1886
Mailing Address - Fax:334-396-1887
Practice Address - Street 1:257 WINTON M BLOUNT LOOP
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3507
Practice Address - Country:US
Practice Address - Phone:334-396-1886
Practice Address - Fax:336-396-1887
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.77363AS0400X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALR61942Medicare UPIN
AL000060847Medicare ID - Type Unspecified