Provider Demographics
NPI:1760947329
Name:KRESCA, ELLEN MARGARET (PA-C)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:MARGARET
Last Name:KRESCA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:MARGARET
Other - Last Name:RANDALL
Other - Suffix:
Other - Last Name Type:Former Name
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 1:705 RILEY HOSPITAL DR STE 2514
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-948-0345
Practice Address - Fax:317-948-0939
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002625A363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300025053Medicaid
IN074790058OtherMEDICARE
IN300018945Medicaid