Provider Demographics
NPI:1235480724
Name:DAKE, MEGAN LYNN KELLY (PA)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:LYNN KELLY
Last Name:DAKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:LYNN
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8433 HARCOURT RD STE 100
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2193
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8433 HARCOURT RD STE 100
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2193
Practice Address - Country:US
Practice Address - Phone:317-583-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001467A363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN558430044Medicare PIN