Healthcare Provider Details

I. General information

NPI: 1619910312
Provider Name (Legal Business Name): ROBERTA CRAFT P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 09/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 W 16TH ST SUITE 5100
INDIANAPOLIS IN
46202-2207
US

IV. Provider business mailing address

8333 NAAB RD SUITE 255
INDIANAPOLIS IN
46260-5924
US

V. Phone/Fax

Practice location:
  • Phone: 317-396-1300
  • Fax: 317-924-8472
Mailing address:
  • Phone: 317-396-1300
  • Fax: 317-396-1346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10000229A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: