Healthcare Provider Details

I. General information

NPI: 1346814720
Provider Name (Legal Business Name): ALYSSA GRACE KUSMER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALYSSA FANARA

II. Dates (important events)

Enumeration Date: 05/19/2021
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9465 COUNSELORS ROW STE 200
INDIANAPOLIS IN
46240-3817
US

IV. Provider business mailing address

6687 WIMBLEDON DR
ZIONSVILLE IN
46077-9153
US

V. Phone/Fax

Practice location:
  • Phone: 877-906-9699
  • Fax:
Mailing address:
  • Phone: 317-694-6230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: