Healthcare Provider Details

I. General information

NPI: 1164887618
Provider Name (Legal Business Name): DEBORAH A MASIAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2015
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8050 TOWNSHIP LINE RD
INDIANAPOLIS IN
46260
US

IV. Provider business mailing address

10330 N MERIDIAN ST # 300
INDIANAPOLIS IN
46290-1024
US

V. Phone/Fax

Practice location:
  • Phone: 317-415-8500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number71007939A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number71007939A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number209013677
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number71007939A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: