Provider Demographics
NPI:1851524177
Name:MELBERTH, GENEVIEVE M (PA-C)
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:M
Last Name:MELBERTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:GENEVIEVE
Other - Middle Name:
Other - Last Name:MIDYETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8430 COOPER CREEK BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:UNIVERSITY PARK
Mailing Address - State:FL
Mailing Address - Zip Code:34201-2016
Mailing Address - Country:US
Mailing Address - Phone:941-360-2255
Mailing Address - Fax:941-487-1777
Practice Address - Street 1:8430 COOPER CREEK BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:UNIVERSITY PARK
Practice Address - State:FL
Practice Address - Zip Code:34201-2016
Practice Address - Country:US
Practice Address - Phone:941-360-2255
Practice Address - Fax:941-487-1777
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105065363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CL652ZMedicare PIN