Provider Demographics
NPI:1902877277
Name:GASTON, MELVIN L (PA-C)
Entity type:Individual
Prefix:
First Name:MELVIN
Middle Name:L
Last Name:GASTON
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 1:3714 GUARDIAN AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-2974
Mailing Address - Country:US
Mailing Address - Phone:252-222-5862
Mailing Address - Fax:252-247-9469
Practice Address - Street 1:3714 GUARDIAN AVE
Practice Address - Street 2:SUITE E
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-2974
Practice Address - Country:US
Practice Address - Phone:252-222-5862
Practice Address - Fax:252-247-9469
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10025363AS0400X
GA004688363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292212600Medicaid
FL292212600Medicaid
R41886Medicare UPIN