Provider Demographics
NPI:1275889206
Name:JOHNSTON, MELINDA M (PA-C)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:M
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELINDA
Other - Middle Name:M
Other - Last Name:COESFELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:730 W MARKET ST STE 2K
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-4602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:730 W MARKET ST STE 2K
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-4602
Practice Address - Country:US
Practice Address - Phone:419-996-4011
Practice Address - Fax:419-996-4012
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-27
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.001122363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0069367Medicaid
OHH115560Medicare PIN