Provider Demographics
NPI:1063298016
Name:LARGE, MEGHAN KAITLYN (PA-C)
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:KAITLYN
Last Name:LARGE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8003 CASTLEWAY DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-1946
Mailing Address - Country:US
Mailing Address - Phone:175-761-3353
Mailing Address - Fax:317-343-6562
Practice Address - Street 1:925 S NEBRASKA ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-1874
Practice Address - Country:US
Practice Address - Phone:765-664-7492
Practice Address - Fax:765-664-7492
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10004113A363AM0700X, 363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300081009Medicaid