Provider Demographics
NPI:1679233118
Name:KEMP, SUNDANCE ZXAINE (CAA)
Entity Type:Individual
Prefix:
First Name:SUNDANCE
Middle Name:ZXAINE
Last Name:KEMP
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
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:
Mailing Address - Fax:
Practice Address - Street 1:2401 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3499
Practice Address - Country:US
Practice Address - Phone:765-747-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-25
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL95367H00000X
367H00000X
IN75000098A367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM22404254OtherMEDICARE PTAN
SCPENDINGMedicaid