Provider Demographics
NPI:1396903241
Name:BANET, ANDREA NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:NICOLE
Last Name:BANET
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:ANDREA
Other - Middle Name:NICOLE
Other - Last Name:CLIFFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 UNIVERSITY BLVD
Practice Address - Street 2:SUITE 1295
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-944-9400
Practice Address - Fax:317-944-5645
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-28
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001457A207XX0005X
IN10002134A363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001083244OtherANTHEM PTAN
IN000001300672OtherANTHEM PTAN
IN300015587Medicaid