Provider Demographics
NPI:1043504285
Name:BRODHEAD, JERICA NICHOLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JERICA
Middle Name:NICHOLE
Last Name:BRODHEAD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:STE 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 1:7250 CLEARVISTA DR
Practice Address - Street 2:STE 355
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-4692
Practice Address - Country:US
Practice Address - Phone:317-621-5676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001219A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1487680518OtherGROUP NPI
IN000000741701OtherANTHEM PIN
IN1487680518OtherGROUP NPI
IN266180912Medicare PIN