Provider Demographics
NPI:1336121433
Name:MELVIN, ANDREA R (PAC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:R
Last Name:MELVIN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7648
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-7648
Mailing Address - Country:US
Mailing Address - Phone:270-575-3113
Mailing Address - Fax:270-575-3135
Practice Address - Street 1:2601 KENTUCKY AVE
Practice Address - Street 2:STE 301
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3817
Practice Address - Country:US
Practice Address - Phone:270-575-3113
Practice Address - Fax:270-575-3135
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA802363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9500390100Medicaid
000000512695OtherANTHEM
862893OtherHEALTHLINK
KY9500390100Medicaid
0044210Medicare PIN