Provider Demographics
NPI:1376569889
Name:STORTEBOOM, TRICIA J (PA)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:J
Last Name:STORTEBOOM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3157
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3157
Mailing Address - Country:US
Mailing Address - Phone:770-405-2976
Mailing Address - Fax:770-988-0730
Practice Address - Street 1:790 CHURCH ST NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7282
Practice Address - Country:US
Practice Address - Phone:770-405-2976
Practice Address - Fax:770-988-0730
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104129363A00000X, 363AM0700X
GA9752363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292747100Medicaid
P46183Medicare UPIN
FL292747100Medicaid