Provider Demographics
NPI:1366524134
Name:MELTON, JEREMIAH J (PA-C)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:J
Last Name:MELTON
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 1:1000 36TH ST
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4862
Mailing Address - Country:US
Mailing Address - Phone:772-563-4580
Mailing Address - Fax:772-563-4690
Practice Address - Street 1:1000 36TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4862
Practice Address - Country:US
Practice Address - Phone:772-563-4580
Practice Address - Fax:772-563-4690
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003025135363A00000X, 363AM0700X, 363AS0400X
FLPA9117544363A00000X, 363AS0400X
KS1500902363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220040523Medicaid
KS200001350HMedicaid