Healthcare Provider Details

I. General information

NPI: 1093473100
Provider Name (Legal Business Name): JACOB SAAH FAYIAH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2021
Last Update Date: 12/14/2024
Certification Date: 12/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9998 CROSSPOINT BLVD STE 200
INDIANAPOLIS IN
46256-3307
US

IV. Provider business mailing address

9998 CROSSPOINT BLVD STE 200
INDIANAPOLIS IN
46256-3307
US

V. Phone/Fax

Practice location:
  • Phone: 317-806-8260
  • Fax: 317-806-8296
Mailing address:
  • Phone: 317-579-2150
  • Fax: 317-806-8260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71011992A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: