Provider Demographics
NPI:1417460833
Name:CIULLA, WANDA SANTOS (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:SANTOS
Last Name:CIULLA
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10027 INDIAN BOUNDARY ST
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:IL
Mailing Address - Zip Code:61944-8253
Mailing Address - Country:US
Mailing Address - Phone:217-465-5442
Mailing Address - Fax:
Practice Address - Street 1:509 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:IL
Practice Address - Zip Code:61944-2325
Practice Address - Country:US
Practice Address - Phone:217-465-8053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY085000243208D00000X, 363A00000X, 2083P0500X, 363AM0700X
IL085000243363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine