Provider Demographics
NPI:1609096015
Name:MAKUN, MERANDA DAWN (PTA)
Entity Type:Individual
Prefix:
First Name:MERANDA
Middle Name:DAWN
Last Name:MAKUN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 W IDLEWILD DR
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47710-3145
Mailing Address - Country:US
Mailing Address - Phone:812-401-1936
Mailing Address - Fax:
Practice Address - Street 1:4100 COVERT AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-5559
Practice Address - Country:US
Practice Address - Phone:812-437-6121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002974A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant