=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376513564
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TABITHA SUE MELVIN PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2006
-----------------------------------------------------
Last Update Date | 04/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1005 E TEMPLE ST
-----------------------------------------------------
City | WASHINGTON COURT HOUSE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43160-3600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-208-2550
-----------------------------------------------------
Fax | 740-853-4229
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1005 E TEMPLE ST
-----------------------------------------------------
City | WASHINGTON COURT HOUSE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43160-3600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-208-2550
-----------------------------------------------------
Fax | 740-853-4229
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 50001977
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------