Provider Demographics
NPI:1841233350
Name:DEALTERIS, PATRICIA (PAC)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:DEALTERIS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 FLAXMILL RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:46750-8806
Mailing Address - Country:US
Mailing Address - Phone:260-359-1250
Mailing Address - Fax:
Practice Address - Street 1:1415 FLAXMILL RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:IN
Practice Address - Zip Code:46750-8806
Practice Address - Country:US
Practice Address - Phone:260-359-1250
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000625A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ33518Medicare UPIN
INO90430QQQQMedicare ID - Type Unspecified