Basic Information
| Provider Information | |||||||||
| NPI: | 1366551350 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DETWEILER | ||||||||
| FirstName: | HOWARD | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | N. P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 W LONGEST ST | ||||||||
| Address2: | PO BOX 270 | ||||||||
| City: | PAOLI | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474548821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127233944 | ||||||||
| FaxNumber: | 8127235292 | ||||||||
| Practice Location | |||||||||
| Address1: | 5604 E WHITE OAK LN | ||||||||
| Address2: | |||||||||
| City: | MARENGO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 471408413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123653221 | ||||||||
| FaxNumber: | 8123659502 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 06/20/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 71000802A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 200000890A | 05 | IN | MEDICAID |