Provider Demographics
NPI:1467786848
Name:SKEETERS, EMILY JOHNSON (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:JOHNSON
Last Name:SKEETERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:KATRINA
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7120 CLEARVISTA DR
Practice Address - Street 2:SUITE 4000
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1621
Practice Address - Country:US
Practice Address - Phone:317-621-7444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-01
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99039488A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300005100Medicaid
IN266180128Medicare PIN