Provider Demographics
NPI:1033214945
Name:BIRT, JUDY MOORMAN (NP)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:MOORMAN
Last Name:BIRT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1481 W 10TH STREET
Mailing Address - Street 2:AMB 11
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:46202
Mailing Address - Country:US
Mailing Address - Phone:317-988-2205
Mailing Address - Fax:317-988-4706
Practice Address - Street 1:1481 W 10TH STREET
Practice Address - Street 2:AMB 11 RICHARD L ROUDELOUSH VA MEDICAL CENTER
Practice Address - City:INDIANAPOLIS
Practice Address - State:IL
Practice Address - Zip Code:46202
Practice Address - Country:US
Practice Address - Phone:317-988-2205
Practice Address - Fax:317-988-4706
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001146A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN