Provider Demographics
NPI:1326178138
Name:HARRISON, MELANIE R (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:R
Last Name:HARRISON
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 1:1 PROFESSIONAL PARK DR
Mailing Address - Street 2:SUITE 21
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-6587
Mailing Address - Country:US
Mailing Address - Phone:423-946-4163
Mailing Address - Fax:423-232-6903
Practice Address - Street 1:1 PROFESSIONAL PARK DR
Practice Address - Street 2:SUITE 21
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6587
Practice Address - Country:US
Practice Address - Phone:423-946-4163
Practice Address - Fax:423-232-6903
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN363A00000X
TN1494207P00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3665068Medicaid
TN3665068Medicaid