Provider Demographics
NPI:1154839835
Name:LIPAN, CARLI (PA)
Entity type:Individual
Prefix:
First Name:CARLI
Middle Name:
Last Name:LIPAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CARLI
Other - Middle Name:
Other - Last Name:RIESTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7120 CLEARVISTA DR STE 3200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1662
Practice Address - Country:US
Practice Address - Phone:317-621-7780
Practice Address - Fax:317-621-7783
Is Sole Proprietor?:No
Enumeration Date:2018-01-17
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002422A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300011591Medicaid