Healthcare Provider Details

I. General information

NPI: 1609142066
Provider Name (Legal Business Name): GARRETT NICHOLAS UNGERER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2012
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5177 MCCARTY LN
LAFAYETTE IN
47905-8764
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-8000
  • Fax: 765-838-4758
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2012005136
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2012005136
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number69687
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number30665
License Number StateMN
# 5
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number01099578A
License Number StateIN
# 6
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number85915-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: