Provider Demographics
NPI:1639333446
Name:PORTER, NATASHA E (PA)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:E
Last Name:PORTER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:NATASHA
Other - Middle Name:E
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:250 N SHADELAND AVE STE 200
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:317-962-4836
Mailing Address - Fax:
Practice Address - Street 1:7979 N SHADELAND AVE
Practice Address - Street 2:STE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2042
Practice Address - Country:US
Practice Address - Phone:317-621-4300
Practice Address - Fax:317-621-4301
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001011A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01157122OtherRR MEDICARE
INP01751324OtherRR MEDICARE
IN000000656388OtherANTHEM
IN000000741054OtherANTHEM
INP00900568Medicare PIN
INP01157122OtherRR MEDICARE
INM400063536Medicare PIN
IN266180802Medicare PIN
INP01751324OtherRR MEDICARE
IN000000741054OtherANTHEM