Provider Demographics
NPI:1477620508
Name:MULATA, SINTAHYU (CRNA)
Entity Type:Individual
Prefix:
First Name:SINTAHYU
Middle Name:
Last Name:MULATA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11456 SOUTH BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-7106
Mailing Address - Country:US
Mailing Address - Phone:219-948-8015
Mailing Address - Fax:219-661-1408
Practice Address - Street 1:11456 SOUTH BROADWAY
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7106
Practice Address - Country:US
Practice Address - Phone:219-948-8015
Practice Address - Fax:219-661-1408
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28074199A367500000X
IL430060834367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000189991OtherBCBS OF INDIANA
IL209003179OtherBCBSIL
IN20043140AMedicaid
IN000000189991OtherBCBS OF INDIANA
4300608834Medicare ID - Type UnspecifiedRR - MC