Healthcare Provider Details

I. General information

NPI: 1932393188
Provider Name (Legal Business Name): ROGER W HURLBUT JR. NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5026 W US 52
NEW PALESTINE IN
46163-9770
US

IV. Provider business mailing address

5026 W US 52
NEW PALESTINE IN
46163-9770
US

V. Phone/Fax

Practice location:
  • Phone: 317-861-4838
  • Fax:
Mailing address:
  • Phone: 317-861-4838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71002460A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number71002460A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: