Provider Demographics
NPI:1902213853
Name:MELTON, JEREMY DANIEL (PA-C)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DANIEL
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 1:300 TOWER RD NE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-9404
Mailing Address - Country:US
Mailing Address - Phone:770-427-5717
Mailing Address - Fax:770-427-6744
Practice Address - Street 1:300 TOWER RD NE
Practice Address - Street 2:SUITE 200
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-9404
Practice Address - Country:US
Practice Address - Phone:770-427-5717
Practice Address - Fax:770-427-6744
Is Sole Proprietor?:No
Enumeration Date:2014-07-11
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007238363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant