Provider Demographics
NPI:1790121549
Name:PATTON, CAROL LYNN (NP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:LYNN
Last Name:PATTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:8111 S EMERSON AVE FL 5
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237
Practice Address - Country:US
Practice Address - Phone:317-528-8930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004499A363LA2200X, 363LG0600X
IN28113039A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201181150Medicaid
IN201181150Medicaid
IN267030072Medicare PIN
IN264430142Medicare PIN
INP01382508Medicare PIN