Provider Demographics
NPI:1215459656
Name:MIHALIC, RYAN M (PA-C)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:M
Last Name:MIHALIC
Suffix:
Gender:M
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11700 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-4656
Practice Address - Country:US
Practice Address - Phone:317-688-3139
Practice Address - Fax:317-688-2664
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002241A363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001451903OtherANTHEM PTAN
IN000001452361OtherANTHEM PTAN
IN000001480734OtherANTHEM PTAN
IN1215459656OtherANTHEM PTAN
IN300011856Medicaid
IN000001095206OtherANTHEM PTAN