Provider Demographics
NPI:1720129562
Name:ORTEGON, MARTA E (PA)
Entity Type:Individual
Prefix:
First Name:MARTA
Middle Name:E
Last Name:ORTEGON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARTA
Other - Middle Name:
Other - Last Name:SHANNON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 7112
Mailing Address - Street 2:DEPT 31
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46207-7112
Mailing Address - Country:US
Mailing Address - Phone:317-802-3151
Mailing Address - Fax:317-870-0499
Practice Address - Street 1:8111 S EMERSON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8601
Practice Address - Country:US
Practice Address - Phone:317-528-5261
Practice Address - Fax:317-528-5026
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000728A363A00000X
IN10000728363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN339250C4Medicare PIN