Provider Demographics
NPI:1568707602
Name:HARPER, CARISSA E (PA)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:E
Last Name:HARPER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:E
Other - Last Name:SCHULTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:SUITE 130, PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-963-0860
Mailing Address - Fax:
Practice Address - Street 1:550 UNIVERSITY BLVD
Practice Address - Street 2:STE 1295
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-944-8330
Practice Address - Fax:317-944-7648
Is Sole Proprietor?:No
Enumeration Date:2012-11-30
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001445A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN233690014Medicare PIN