MEDICARE: JILL C PEASE PHYSICIAN ASSISTANT

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	363A00000X	Physician Assistant	10000824A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000540149	OTHER	IN	ANTHEM PROVIDER NUMBER

General Provider Information

NPI Number	:	1619951126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILL C PEASE PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	3554 PROMENADE PKWY
Second Line	:	SUITE H
City	:	LAFAYETTE
State	:	IN
Zip	:	47909-8417
Country	:	US
Telephone Number	:	765-471-1100
Fax Number	:

Provider Business Practice Location Address
First Line	:	3554 PROMENADE PKWY
Second Line	:	SUITE H
City	:	LAFAYETTE
State	:	IN
Zip	:	47909-8417
Country	:	US
Telephone Number	:	765-471-1100
Fax Number	:

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

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	06/16/2015

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Directions to “ JILL C PEASE PHYSICIAN ASSISTANT” Practice Location

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