Healthcare Provider Details

I. General information

NPI: 1013194083
Provider Name (Legal Business Name): MELISSA MARIE CLINTON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6901 SIMMONS LOOP
RIVERVIEW FL
33578
US

IV. Provider business mailing address

2502 W ST. ISABEL ST.
TAMPA FL
33607
US

V. Phone/Fax

Practice location:
  • Phone: 813-302-8070
  • Fax: 813-972-5055
Mailing address:
  • Phone: 813-874-5707
  • Fax: 813-972-5055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9104486
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: