Provider Demographics
NPI:1235587932
Name:BAIN, TESS MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:TESS
Middle Name:MARIE
Last Name:BAIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TESS
Other - Middle Name:MARIE
Other - Last Name:RUDOLPH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3600 W BETHEL AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5407
Mailing Address - Country:US
Mailing Address - Phone:317-455-1064
Mailing Address - Fax:317-455-1204
Practice Address - Street 1:6920 GATWICK DR STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241
Practice Address - Country:US
Practice Address - Phone:317-455-1064
Practice Address - Fax:317-455-1204
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007808363A00000X
IN10002761A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant