Provider Demographics
NPI:1003392440
Name:YODER, CORTNIE N
Entity Type:Individual
Prefix:
First Name:CORTNIE
Middle Name:N
Last Name:YODER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:317-621-7588
Mailing Address - Fax:317-957-2749
Practice Address - Street 1:1402 E COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-0963
Practice Address - Country:US
Practice Address - Phone:317-887-7805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002556A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300018552Medicaid
IN266180C42OtherTRADITIONAL MEDICARE
INP02110480OtherMEDICARE RR