Provider Demographics
NPI:1295155679
Name:KHAN, MELISSA TUCKER (PA-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:TUCKER
Last Name:KHAN
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 1:100 S CHARLES ST
Mailing Address - Street 2:#150
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-2725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6475 JIMMY CARTER BLVD STE 200
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-1734
Practice Address - Country:US
Practice Address - Phone:770-242-7744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005378363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant