Healthcare Provider Details

I. General information

NPI: 1568280279
Provider Name (Legal Business Name): ANNA MARIE RESTIVO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2024
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7150 CLEARVISTA DR
INDIANAPOLIS IN
46256-1695
US

IV. Provider business mailing address

6626 E 75TH ST STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 317-355-5041
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number10004562A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10004562A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: