Provider Demographics
NPI:1780197673
Name:STROUD, GABRIELLE C (PA-C)
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:C
Last Name:STROUD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:GABRIELLE
Other - Middle Name:C
Other - Last Name:BATES
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 1:9650 E WASHINGTON ST STE 100
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-3032
Practice Address - Country:US
Practice Address - Phone:317-890-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00454900363A00000X
IN10002876A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN266430990OtherMEDICARE
IN300037623Medicaid