Provider Demographics
NPI:1861912545
Name:BOGENSCHUTZ, KEVIN (PA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BOGENSCHUTZ
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 1:2035 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-1760
Mailing Address - Country:US
Mailing Address - Phone:513-504-9396
Mailing Address - Fax:
Practice Address - Street 1:7911 MICHIGAN RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-1915
Practice Address - Country:US
Practice Address - Phone:317-956-6288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant