Provider Demographics
NPI:1801245725
Name:GARRETT, MELBURN (PA-C)
Entity type:Individual
Prefix:
First Name:MELBURN
Middle Name:
Last Name:GARRETT
Suffix:
Gender:M
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 1:3744 S TIMBERLINE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4334
Mailing Address - Country:US
Mailing Address - Phone:970-495-0506
Mailing Address - Fax:970-495-0485
Practice Address - Street 1:3744 S TIMBERLINE RD
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-4333
Practice Address - Country:US
Practice Address - Phone:970-495-0506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-10
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109576363A00000X, 363AM0700X, 363AS0400X
COPA.0006441363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003179847AMedicaid
FL017896300Medicaid
FLIQ266ZMedicare PIN