Provider Demographics
NPI:1639274848
Name:HETTERMANN, JODI A (PA-C)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:A
Last Name:HETTERMANN
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 1:13225 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-5480
Mailing Address - Country:US
Mailing Address - Phone:317-228-7000
Mailing Address - Fax:317-228-9029
Practice Address - Street 1:13225 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-5480
Practice Address - Country:US
Practice Address - Phone:317-228-7000
Practice Address - Fax:317-228-2321
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000571A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000340579OtherANTHEM PROVIDER NUMBER
IN000000340579OtherUNICARE PROVIDER NUMBER
IN000000340579OtherANTHEM PROVIDER NUMBER
INP00226392Medicare ID - Type UnspecifiedMEDICARE RAILROAD
IN186950JMedicare ID - Type Unspecified