Provider Demographics
NPI:1104128214
Name:FRICKE, MEGHAN KYLE
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:KYLE
Last Name:FRICKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46176-1236
Mailing Address - Country:US
Mailing Address - Phone:317-398-5275
Mailing Address - Fax:
Practice Address - Street 1:860 E 86TH ST STE 4
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240
Practice Address - Country:US
Practice Address - Phone:317-975-3441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-22
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001248A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000713740OtherANTHEM BC/BS
IN000000713740OtherANTHEM BC/BS