Individual
NICOLE ANTAO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
7120 CLEARVISTA DR, SUITE 2100, INDIANAPOLIS, IN 46256-1621
(317) 621-2740
(317) 621-5658
Mailing address
6626 E 75TH ST, SUITE 500, INDIANAPOLIS, IN 46250-2805
(317) 621-9002
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
10001023
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
P01212100
RR MEDICARE PTAN
IN
Enumeration date
09/26/2008
Last updated
11/27/2023
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