Provider Demographics
NPI:1568719060
Name:EMMETT, JOHN SCOTT (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:SCOTT
Last Name:EMMETT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:355 W 16TH ST STE 3200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2280
Practice Address - Country:US
Practice Address - Phone:317-948-5450
Practice Address - Fax:317-887-7664
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
UT8375969363AM0700X
IN10002029A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300005189Medicaid
INP01824430OtherRR MEDICARE
IN300005189Medicaid