Provider Demographics
NPI:1194993972
Name:MELLENTHIN, JEREME EDWIN (PA)
Entity type:Individual
Prefix:
First Name:JEREME
Middle Name:EDWIN
Last Name:MELLENTHIN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:US DEPT OF STATE
Mailing Address - Street 2:M/MED/QI, SA-1
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20522-0001
Mailing Address - Country:US
Mailing Address - Phone:202-663-2453
Mailing Address - Fax:202-663-3247
Practice Address - Street 1:US DEPT OF STATE
Practice Address - Street 2:M/MED/QI, SA-1
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20522-0001
Practice Address - Country:US
Practice Address - Phone:202-663-2453
Practice Address - Fax:202-663-3247
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103637363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant