Provider Demographics
NPI:1588646889
Name:MELLON, MICHAEL (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MELLON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 S 2ND ST STE 2F
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:717-782-3282
Mailing Address - Fax:
Practice Address - Street 1:1500 HIGHLANDS DR
Practice Address - Street 2:
Practice Address - City:LITITZ
Practice Address - State:PA
Practice Address - Zip Code:17543
Practice Address - Country:US
Practice Address - Phone:717-782-3282
Practice Address - Fax:717-231-8964
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN261026L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001746512Medicaid
PA013552Medicare PIN
S61937Medicare UPIN