Individual
JIMMY MIDENCE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PTA
Contact information
Practice address
4205 SUNSHINE AVE, INDIANAPOLIS, IN 46228
(317) 937-1134
Mailing address
4205 SUNSHINE AVE, INDIANAPOLIS, IN 46228
(317) 937-1134
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
99094830A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
853356262
UHC
IN
Enumeration date
09/20/2019
Last updated
02/15/2022
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