Unknown Individual – Family Nurse Practitioner, NPI 1063411072

Family Nurse Practitioner

Unknown Individual is a healthcare provider. based in Peru, Indiana. specializing in Family Nurse Practitioner. They hold a License No. 71000359A (IN). The NPI Number for Unknown Individual is 1063411072

Main info

Organization

Inactive

29 Years Of Experience

Accepts Medicare Assignment

Name

Unknown Individual

NPI

1063411072

Phone

(765) 475-2316

Address

275 W 12TH ST

Deactivation Date

10 June 2021

Doctor Profile

Medical School Name

OTHER

Secondary Phone

2603532190

Graduation Year

1997 (29 years ago)

PAC ID

1658273990

Group Practice PAC ID

8628988367

Professional Enrollment ID

I20040126000621

Data current as of

19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology

Experience19

Completeness75

Years active:0State licenses:1Digital endpointsOther names

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Provider Addresses for Unknown Individual

Dukes Memorial Hospital, 275, West 12th Street, Ridgeview, Peru, Miami County, Indiana, 46970, United States
SUITE 103
PERU, IN 469701638
Phone: (765) 475-2316
Fax: (765) 475-2359
Mailing address matches the actual address.

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

No Open Payments data available for this provider.

This can happen when there are no reportable CMS Open Payments records.

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 46970)

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Provider's Procedures

Unknown Individual performs procedures in Family Nurse Practitioner. See the list of HCPCS codes below.

Specialty	Practice State	HCPCS Code	Description	Service Count	Beneficiary Count
NURSE PRACTITIONER	IN	81002	Urinalysis, manual test	14	12

Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.

PAC ID: 8628988367View full group profile

Name	Specialty	State
JAMIE A MATZ (NP)	Nurse Practitioner	IN
ROLAND STUCKEY (MD)	-	IN
PATRICIA CAMPBELL (NP)	-	IN
MICHAEL LEE STEVELEY (PA-C)	-	IN
ROBERT J SPEARS (PAC)	-	OH
DELYNN HOWARD ELZEY (MD)	-	IN
STACEY M. KRICK (PA)	-	IN
LORRAINE CONKLIN (PAC)	-	IN
RAMONA FAY BAUCH (PAC)	Physician Assistant	IN
DEBORAH S CASTILE (P.A.)	-	IN