Provider Demographics
NPI:1255529442
Name:BLOM, MELINDA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:MARIE
Last Name:BLOM
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 1:12953 PALMS WEST DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LOXAHATCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:33470-4990
Mailing Address - Country:US
Mailing Address - Phone:561-795-5130
Mailing Address - Fax:561-795-4160
Practice Address - Street 1:12953 PALMS WEST DR
Practice Address - Street 2:SUITE 201
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-4990
Practice Address - Country:US
Practice Address - Phone:561-795-5130
Practice Address - Fax:561-795-4160
Is Sole Proprietor?:No
Enumeration Date:2007-10-12
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104374363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL230482OtherAMERIGROUP
FL230482OtherAMERIGROUP
FL33803AMedicare PIN