MEDICARE: BRAXTON R SHIDLER FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	71012197A	IN

General Provider Information

NPI Number	:	1013660786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRAXTON R SHIDLER FNP

Provider Business Mailing Address
First Line	:	6626 E 75TH ST STE 500
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250-2890
Country	:	US
Telephone Number	:	317-621-7547
Fax Number	:

Provider Business Practice Location Address
First Line	:	8205 E 56TH ST STE 100
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46216-1069
Country	:	US
Telephone Number	:	317-621-1006
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2022
Last Update Date	:	05/05/2025

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