Provider Demographics
NPI:1013194083
Name:CLINTON, MELISSA MARIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:MARIE
Last Name:CLINTON
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 1:2502 W ST. ISABEL ST.
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607
Mailing Address - Country:US
Mailing Address - Phone:813-874-5707
Mailing Address - Fax:813-972-5055
Practice Address - Street 1:6901 SIMMONS LOOP
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578
Practice Address - Country:US
Practice Address - Phone:813-302-8070
Practice Address - Fax:813-972-5055
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104486363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL293023400Medicaid
FLY04EQOtherBC/BS
FLP00865655OtherRAILROAD MEDICARE
FLA1281ZMedicare PIN