Provider Demographics
NPI:1588966998
Name:BUNCH, LISA K (NP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:BUNCH
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 - PROVIDER ENROLLMENT
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 1:1633 N CAPITOL AVE
Practice Address - Street 2:STE 322
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1476
Practice Address - Country:US
Practice Address - Phone:317-962-2929
Practice Address - Fax:317-962-2070
Is Sole Proprietor?:No
Enumeration Date:2010-11-18
Last Update Date:2015-05-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN28092723A363LA2200X
IN71003487A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201005500Medicaid
IN264430117Medicare PIN
INM400034856Medicare PIN
INP01438574Medicare PIN