Provider Demographics
NPI:1366074817
Name:MELTON, RETHA MARCELEEN (PA-C)
Entity type:Individual
Prefix:
First Name:RETHA
Middle Name:MARCELEEN
Last Name:MELTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:RETHA
Other - Middle Name:MARCELEEN
Other - Last Name:DAWES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1155 W. PARKVIEW ST.
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613
Mailing Address - Country:US
Mailing Address - Phone:417-733-0262
Mailing Address - Fax:
Practice Address - Street 1:1155 W. PARKVIEW ST
Practice Address - Street 2:SUITE 2D
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613
Practice Address - Country:US
Practice Address - Phone:417-777-2663
Practice Address - Fax:417-777-2666
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020005350363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant