Provider Demographics
NPI:1174888135
Name:PERRY, SHURIKA LYDEL (PA)
Entity type:Individual
Prefix:
First Name:SHURIKA
Middle Name:LYDEL
Last Name:PERRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1533 CHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1914
Mailing Address - Country:US
Mailing Address - Phone:317-319-2514
Mailing Address - Fax:
Practice Address - Street 1:1533 CHESTER BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1914
Practice Address - Country:US
Practice Address - Phone:317-319-2514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-05
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001424A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000779072OtherANTHEM
INM400075339Medicare PIN