Provider Demographics
NPI:1194807651
Name:CLARY, MELISSA L (PA-C)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:L
Last Name:CLARY
Suffix:
Gender:F
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 1:100 HAWTHORN LN
Mailing Address - Street 2:
Mailing Address - City:DANIELS
Mailing Address - State:WV
Mailing Address - Zip Code:25832-9269
Mailing Address - Country:US
Mailing Address - Phone:304-763-8555
Mailing Address - Fax:
Practice Address - Street 1:1709 EAST BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5823
Practice Address - Country:US
Practice Address - Phone:704-333-6642
Practice Address - Fax:704-332-6642
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01237363A00000X
NC0010-03356363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001913138OtherMS BCBS
WV3810007173Medicaid
WV2028001Medicare PIN
WV2028004Medicare PIN
WV2028003Medicare PIN
WV2028002Medicare PIN
WV001913138OtherMS BCBS
WV3810007173Medicaid