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General NPI Number Information
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NPI Number | 1417460833
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Entity Type | Individual
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Provider Name | WANDA SANTOS CIULLA PHYSICIAN ASSISTANT
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Gender | Female
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Dates
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Enumeration Date | 11/07/2017
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Last Update Date | 11/07/2017
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Provider Practice Location Address
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Address Line | 509 S MAIN ST
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City | PARIS
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State | IL
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Zip | 61944-2325
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Country | US
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Telephone | 217-465-8053
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Fax |
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Provider Business Mailing Address
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Address Line | 10027 INDIAN BOUNDARY ST
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City | PARIS
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State | IL
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Zip | 61944-8253
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Country | US
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Telephone | 217-465-5442
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 085000243
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 085000243
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License Number State | NY
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Taxonomy #3
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Taxonomy Code | 2083P0500X
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Taxonomy Name | Preventive Medicine/Occupational Environmental Medicine Physician
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License Number | 085000243
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License Number State | NY
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Taxonomy #4
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 085000243
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License Number State | IL
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Taxonomy #5
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 085000243
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License Number State | NY
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