Provider Demographics
NPI:1265516751
Name:ELAM, LAINE (PAC)
Entity type:Individual
Prefix:MRS
First Name:LAINE
Middle Name:
Last Name:ELAM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:LAINE
Other - Middle Name:
Other - Last Name:BEATY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 W PURDUE AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-6357
Mailing Address - Country:US
Mailing Address - Phone:765-747-6090
Mailing Address - Fax:765-747-5069
Practice Address - Street 1:2525 W UNIVERSITY AVE STE 402
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3409
Practice Address - Country:US
Practice Address - Phone:765-747-6090
Practice Address - Fax:765-747-5069
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000270A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INS58873Medicare UPIN
IN202830EMedicare ID - Type UnspecifiedMEDICARE