Provider Demographics
NPI:1972531119
Name:CHILD, MELVIN RAUN (PA)
Entity Type:Individual
Prefix:
First Name:MELVIN
Middle Name:RAUN
Last Name:CHILD
Suffix:
Gender:M
Credentials:PA
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 842
Mailing Address - Street 2:
Mailing Address - City:FILLMORE
Mailing Address - State:UT
Mailing Address - Zip Code:84631-0842
Mailing Address - Country:US
Mailing Address - Phone:435-979-2487
Mailing Address - Fax:
Practice Address - Street 1:150 E 500 N
Practice Address - Street 2:
Practice Address - City:FILLMORE
Practice Address - State:UT
Practice Address - Zip Code:84631-3514
Practice Address - Country:US
Practice Address - Phone:435-979-2487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0400X
UT106923-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTS27902Medicare UPIN