Provider Demographics
NPI:1073588844
Name:SHORT, BRIAN J (NP)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:SHORT
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4620 MIDDLEBORO LANE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374
Mailing Address - Country:US
Mailing Address - Phone:765-966-1391
Mailing Address - Fax:
Practice Address - Street 1:4620 MIDDLEBORO LANE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374
Practice Address - Country:US
Practice Address - Phone:765-966-1391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001054A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000731844OtherANTHEM BCBS
IN200361020Medicaid
IN200361020Medicaid