Provider Demographics
NPI:1164018941
Name:MANN, PATRICK L (PA-C)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:L
Last Name:MANN
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 1:2445 DIRECTORS ROW STE C
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46241-4936
Mailing Address - Country:US
Mailing Address - Phone:317-941-7338
Mailing Address - Fax:
Practice Address - Street 1:2445 DIRECTORS ROW STE C
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-4936
Practice Address - Country:US
Practice Address - Phone:317-941-7338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-16
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003150A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300046250Medicaid