Provider Demographics
NPI:1629182340
Name:MCCLAIN, MELISSA BAILEY (PA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:BAILEY
Last Name:MCCLAIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:L
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1040 PARK AVENUE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201
Mailing Address - Country:US
Mailing Address - Phone:443-738-0300
Mailing Address - Fax:443-738-0301
Practice Address - Street 1:1040 PARK AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201
Practice Address - Country:US
Practice Address - Phone:443-738-0300
Practice Address - Fax:443-738-0301
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC06854363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD043104400Medicaid
GA537480118BMedicaid
GAQ71061Medicare UPIN