Healthcare Provider Details

I. General information

NPI: 1417460833
Provider Name (Legal Business Name): WANDA SANTOS CIULLA PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2017
Last Update Date: 11/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 S MAIN ST
PARIS IL
61944-2325
US

IV. Provider business mailing address

10027 INDIAN BOUNDARY ST
PARIS IL
61944-8253
US

V. Phone/Fax

Practice location:
  • Phone: 217-465-8053
  • Fax:
Mailing address:
  • Phone: 217-465-5442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number085000243
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085000243
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number085000243
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085000243
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085000243
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: