Provider Demographics
NPI:1316906084
Name:MELTON, RICKEY LEE (CSA / KCSA)
Entity type:Individual
Prefix:MR
First Name:RICKEY
Middle Name:LEE
Last Name:MELTON
Suffix:
Gender:M
Credentials:CSA / KCSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1298 MILLERTOWN RD
Mailing Address - Street 2:
Mailing Address - City:ROCKHOLDS
Mailing Address - State:KY
Mailing Address - Zip Code:40759-7638
Mailing Address - Country:US
Mailing Address - Phone:606-627-8575
Mailing Address - Fax:
Practice Address - Street 1:1298 MILLERTOWN RD
Practice Address - Street 2:
Practice Address - City:ROCKHOLDS
Practice Address - State:KY
Practice Address - Zip Code:40759-7638
Practice Address - Country:US
Practice Address - Phone:606-627-8575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3428363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical