1194807651 NPI number — MELISSA L CLARY PA-C

Table of content: MELISSA L CLARY PA-C (NPI 1194807651)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194807651 NPI number — MELISSA L CLARY PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLARY
Provider First Name:
MELISSA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194807651
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 HAWTHORN LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DANIELS
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25832-9269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-763-8555
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1709 EAST BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28203-5823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-333-6642
Provider Business Practice Location Address Fax Number:
704-332-6642
Provider Enumeration Date:
10/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  01237 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 0010-03356 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001913138 . This is a "MS BCBS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 3810007173 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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