Provider Demographics
NPI:1699373357
Name:ETTER, DILLON (PA-C)
Entity Type:Individual
Prefix:
First Name:DILLON
Middle Name:
Last Name:ETTER
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 1:25 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:IN
Mailing Address - Zip Code:47102-1303
Mailing Address - Country:US
Mailing Address - Phone:812-794-8100
Mailing Address - Fax:
Practice Address - Street 1:5515 W 38TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-2919
Practice Address - Country:US
Practice Address - Phone:317-880-3838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IN10003062A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty