Provider Demographics
NPI:1891352407
Name:MELTON, JASON DUANE (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:DUANE
Last Name:MELTON
Suffix:
Gender:M
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:PO BOX 1341
Mailing Address - Street 2:
Mailing Address - City:CHINO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86323-1341
Mailing Address - Country:US
Mailing Address - Phone:928-963-1298
Mailing Address - Fax:
Practice Address - Street 1:87 S HWY 89
Practice Address - Street 2:
Practice Address - City:CHINO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86323-5687
Practice Address - Country:US
Practice Address - Phone:928-208-4309
Practice Address - Fax:928-227-1229
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-20
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8052363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty