1033754734 NPI number — MITCHELL NEWTON NETTLETON PA-C

Table of content: MITCHELL NEWTON NETTLETON PA-C (NPI 1033754734)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033754734 NPI number — MITCHELL NEWTON NETTLETON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NETTLETON
Provider First Name:
MITCHELL
Provider Middle Name:
NEWTON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033754734
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
421 E MARKET ST APT 328S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46204-2864
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-325-3735
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13100 E 136TH ST STE 3600
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FISHERS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46037-9822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-962-3700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/18/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  10002860A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)