Basic Information
| Provider Information | |||||||||
| NPI: | 1558762542 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIDIER | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OTTENWELLER | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3640 NEW VISION DRIVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468451717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604824440 | ||||||||
| FaxNumber: | 2604824442 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 RANDALLIA DR | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468054638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603734000 | ||||||||
| FaxNumber: | 2604824442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2014 | ||||||||
| LastUpdateDate: | 10/28/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.