Provider Demographics
NPI:1588610752
Name:KANTZAVELOS, ANNA A (PA-C)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:A
Last Name:KANTZAVELOS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:A
Other - Last Name:AMERICANOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6640 PARKDALE PL
Mailing Address - Street 2:SUITE K
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-5656
Mailing Address - Country:US
Mailing Address - Phone:317-216-3033
Mailing Address - Fax:317-216-6093
Practice Address - Street 1:1800 N CAPITOL AVE
Practice Address - Street 2:NOYES PAVILION E140
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1218
Practice Address - Country:US
Practice Address - Phone:317-962-2894
Practice Address - Fax:317-963-5285
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000758A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN165460GGGMedicare ID - Type Unspecified
INQ28685Medicare UPIN