Provider Demographics
NPI:1720081227
Name:MELLOTT, ERIN L (PA)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:L
Last Name:MELLOTT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 1ST ST.
Mailing Address - Street 2:
Mailing Address - City:LIMON
Mailing Address - State:CO
Mailing Address - Zip Code:80828-1120
Mailing Address - Country:US
Mailing Address - Phone:719-775-2367
Mailing Address - Fax:719-775-2365
Practice Address - Street 1:820 1ST ST.
Practice Address - Street 2:
Practice Address - City:LIMON
Practice Address - State:CO
Practice Address - Zip Code:80828-1120
Practice Address - Country:US
Practice Address - Phone:719-775-2367
Practice Address - Fax:719-775-2365
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2037363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO76000311Medicaid
COQ34802Medicare UPIN