Basic Information
| Provider Information | |||||||||
| NPI: | 1508455247 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORN | ||||||||
| FirstName: | AUDREY | ||||||||
| MiddleName: | BROOKE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1028 GRAY SQUIRREL DR | ||||||||
| Address2: | |||||||||
| City: | PENDLETON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460649168 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9002 N MERIDIAN ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462602301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178445530 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2021 | ||||||||
| LastUpdateDate: | 01/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 10003168A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.