Provider Demographics
NPI:1578544110
Name:DURHAM, MELANIE M (PA-C)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:M
Last Name:DURHAM
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 1:1222 TROTWOOD AVE
Mailing Address - Street 2:SUITE 211
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-6436
Mailing Address - Country:US
Mailing Address - Phone:931-380-3033
Mailing Address - Fax:931-388-3401
Practice Address - Street 1:1222 TROTWOOD AVE
Practice Address - Street 2:SUITE 211
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-6436
Practice Address - Country:US
Practice Address - Phone:931-380-3033
Practice Address - Fax:931-388-3401
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN992363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3669739Medicaid
TNP79066Medicare UPIN
TN3669739Medicare ID - Type Unspecified