Provider Demographics
NPI:1811950272
Name:MELDRUM, JACLYN TYO (PA-C)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:TYO
Last Name:MELDRUM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:MICHELLE
Other - Last Name:TYO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5191 FIRST COAST TECH PKWY FL 3
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-0609
Mailing Address - Country:US
Mailing Address - Phone:904-223-3321
Mailing Address - Fax:904-223-2169
Practice Address - Street 1:5191 FIRST COAST TECH PKWY FL 3
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-0609
Practice Address - Country:US
Practice Address - Phone:904-223-3321
Practice Address - Fax:904-223-2169
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103502363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292340800Medicaid
Q54820Medicare UPIN
FLU6240Medicare ID - Type Unspecified