Provider Demographics
NPI:1548283823
Name:ROSCOE, MICHAEL SHANNON (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHANNON
Last Name:ROSCOE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 W 46TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-3602
Mailing Address - Country:US
Mailing Address - Phone:317-940-6026
Mailing Address - Fax:
Practice Address - Street 1:5165 MCCARTY LN
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-8764
Practice Address - Country:US
Practice Address - Phone:765-838-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2014-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000397A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P02801Medicare UPIN