Provider Demographics
NPI:1902021892
Name:DEROSE, BARBARA S (NP)
Entity Type:Individual
Prefix:
First Name:BARBARA
Middle Name:S
Last Name:DEROSE
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 1:6626 E 75TH ST
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11020 PENDLETON PIKE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46236-2817
Practice Address - Country:US
Practice Address - Phone:317-826-3903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28072442A163W00000X
IN71002477A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN266180942Medicare PIN