Provider Demographics
NPI:1780346692
Name:GARRIOTT, WILLIAM ANDREW II
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:ANDREW
Last Name:GARRIOTT
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6910 N TUXEDO ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-3776
Mailing Address - Country:US
Mailing Address - Phone:317-777-1763
Mailing Address - Fax:
Practice Address - Street 1:120 E MARKET ST STE 715D
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-3237
Practice Address - Country:US
Practice Address - Phone:317-777-1763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71011553A363LP0808X, 363LP0808X
IN1780346692363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300055795Medicaid