Provider Demographics
NPI:1972558476
Name:MATHIS, MELISSA CLINE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:CLINE
Last Name:MATHIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:CLINE
Other - Last Name:LOOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 744786
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4786
Mailing Address - Country:US
Mailing Address - Phone:704-834-2450
Mailing Address - Fax:704-671-5331
Practice Address - Street 1:2555 COURT DR STE 350
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2186
Practice Address - Country:US
Practice Address - Phone:704-834-2465
Practice Address - Fax:704-834-2466
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05141363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0303PAMedicaid
SCQ39720Medicare UPIN
SC0303PAMedicaid