Provider Demographics
NPI:1962956789
Name:COLE, STACIE (PA)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:COLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:
Other - Last Name:COPPLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 N RITTER AVE
Practice Address - Street 2:STE 375B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3052
Practice Address - Country:US
Practice Address - Phone:317-355-9370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2017-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002079A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01723958Medicare PIN
IN266180723Medicare PIN