Provider Demographics
NPI:1578808945
Name:MELA, JAC-LYN (PA)
Entity Type:Individual
Prefix:
First Name:JAC-LYN
Middle Name:
Last Name:MELA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 6TH ST S STE 320
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4824
Mailing Address - Country:US
Mailing Address - Phone:727-767-8590
Mailing Address - Fax:727-767-4319
Practice Address - Street 1:880 6TH ST S STE 320
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4824
Practice Address - Country:US
Practice Address - Phone:727-767-8590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-11
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107044363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0081289-00Medicaid
FLGX973ZMedicare PIN