Healthcare Provider Details

I. General information

NPI: 1700475951
Provider Name (Legal Business Name): ALYSSA MARIE CARTIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3118 S LAFOUNTAIN ST
KOKOMO IN
46902-3710
US

IV. Provider business mailing address

8003 CASTLEWAY DR
INDIANAPOLIS IN
46250-1946
US

V. Phone/Fax

Practice location:
  • Phone: 765-864-4160
  • Fax: 765-400-4467
Mailing address:
  • Phone: 317-576-1335
  • Fax: 317-343-6562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10003323A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: