Provider Demographics
NPI:1578178331
Name:STALETS, MAKENZIE E (PA-C)
Entity Type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:E
Last Name:STALETS
Suffix:
Gender:F
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 1:9011 N MERIDIAN ST STE 225
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-5365
Mailing Address - Country:US
Mailing Address - Phone:317-574-4747
Mailing Address - Fax:317-574-4737
Practice Address - Street 1:8205 E 56TH ST STE 250
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46216-1097
Practice Address - Country:US
Practice Address - Phone:317-353-8985
Practice Address - Fax:317-353-2389
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003081A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10003081AOtherPA LICENSE
IN300045170Medicaid