=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073859732
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN COLIN CULBERTSON PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2012
-----------------------------------------------------
Last Update Date | 07/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4526 NORTHPORT BLVD
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71107-2536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-935-9626
-----------------------------------------------------
Fax | 318-489-4181
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3515 RICHMOND RD
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503-0711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-791-9355
-----------------------------------------------------
Fax | 903-793-0496
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA.200663
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------