Provider Demographics
NPI:1538668140
Name:CROCKER, MELISSA M (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
Last Name:CROCKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:CLEMENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1708
Mailing Address - Country:US
Mailing Address - Phone:270-783-3343
Mailing Address - Fax:270-780-0476
Practice Address - Street 1:201 PARK ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1708
Practice Address - Country:US
Practice Address - Phone:270-783-3343
Practice Address - Fax:270-780-0476
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA088778363A00000X
363A00000X
KYTC980363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant