Provider Demographics
NPI:1689872830
Name:PRIDDIS, THOMAS L (PA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:L
Last Name:PRIDDIS
Suffix:
Gender:M
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 1:429 N PENNSYLVANIA ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-1815
Mailing Address - Country:US
Mailing Address - Phone:317-791-6691
Mailing Address - Fax:317-791-6680
Practice Address - Street 1:429 NORTH PENNSYLVANIA STREET,
Practice Address - Street 2:SUITE 400
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-0001
Practice Address - Country:US
Practice Address - Phone:317-791-6691
Practice Address - Fax:317-791-6680
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000934A363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical