Provider Demographics
NPI:1780846428
Name:BARTLEY, DAMON TROY (PA)
Entity type:Individual
Prefix:
First Name:DAMON
Middle Name:TROY
Last Name:BARTLEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3019 N NATIONAL RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-3235
Mailing Address - Country:US
Mailing Address - Phone:812-314-7617
Mailing Address - Fax:812-314-7618
Practice Address - Street 1:3019 N NATIONAL RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-3235
Practice Address - Country:US
Practice Address - Phone:812-314-7617
Practice Address - Fax:812-314-7618
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-003027363AS0400X
363AS0400X
IN10001498A363AS0400X, 363A00000X
TN1601363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1508056Medicaid