Provider Demographics
NPI:1366678088
Name:DAMITZ, EMILY A (PA)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:A
Last Name:DAMITZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:A
Other - Last Name:ALBERTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1225 E COOLSPRING AVE STE 300
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-6312
Practice Address - Country:US
Practice Address - Phone:219-878-5032
Practice Address - Fax:219-878-5052
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001102A363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0449980001Medicare NSC
IN0449980008Medicare NSC
IN473320NNNMedicare PIN
IN0449980013Medicare NSC