Provider Demographics
NPI:1437239738
Name:MELTON, RAY (NP)
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:
Last Name:MELTON
Suffix:
Gender:M
Credentials:NP
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 24146
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-2416
Mailing Address - Country:US
Mailing Address - Phone:601-925-6805
Mailing Address - Fax:601-926-4978
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4505
Practice Address - Country:US
Practice Address - Phone:601-984-5100
Practice Address - Fax:601-926-4978
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR556572363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00118905Medicaid
MS302I507640Medicare PIN
MS00118905Medicaid
MS500001343Medicare ID - Type Unspecified