Provider Demographics
NPI:1528317518
Name:LASTER, JERWANA (DPM)
Entity type:Individual
Prefix:DR
First Name:JERWANA
Middle Name:
Last Name:LASTER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10935 BEECHWOOD DR E
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46280-1222
Mailing Address - Country:US
Mailing Address - Phone:317-441-1093
Mailing Address - Fax:317-669-2739
Practice Address - Street 1:10935 BEECHWOOD DR E
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46280-1222
Practice Address - Country:US
Practice Address - Phone:317-441-1093
Practice Address - Fax:317-669-2739
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001149A213EP1101X
TN794213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN07001149BOtherIN LICENSE
TN794OtherTN LICENSE