Provider Demographics
NPI:1275517054
Name:MELVIN, WILLIAM STACY (PA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:STACY
Last Name:MELVIN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 PROFESSIONAL PARK DR
Mailing Address - Street 2:SUITE 21
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6529
Mailing Address - Country:US
Mailing Address - Phone:423-434-6300
Mailing Address - Fax:423-434-6312
Practice Address - Street 1:3 PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE 21
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6529
Practice Address - Country:US
Practice Address - Phone:423-434-6300
Practice Address - Fax:423-434-6312
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009362-1363A00000X
TN1608363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1507350Medicaid
TN1507350Medicaid
TNP91429Medicare UPIN