Provider Demographics
NPI:1639540123
Name:MURRAY, MELANIE GLENN (PA-C)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:GLENN
Last Name:MURRAY
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 1:21821 CONSTANCIA
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-1017
Mailing Address - Country:US
Mailing Address - Phone:949-533-1135
Mailing Address - Fax:
Practice Address - Street 1:17271 BROOKHURST ST
Practice Address - Street 2:SUITE A
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-3701
Practice Address - Country:US
Practice Address - Phone:714-531-2966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52948363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant