Provider Demographics
NPI:1942450986
Name:ANTAO, NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:ANTAO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:317-621-9002
Mailing Address - Fax:
Practice Address - Street 1:7120 CLEARVISTA DR
Practice Address - Street 2:SUITE 2100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1621
Practice Address - Country:US
Practice Address - Phone:317-621-2740
Practice Address - Fax:317-621-5658
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN10001023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01212100OtherRR MEDICARE PTAN
INP01212100OtherRR MEDICARE PTAN