Provider Demographics
NPI:1588676985
Name:CULLEN, KATHLEEN (PA)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:CULLEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21202 OLEAN BLVD
Mailing Address - Street 2:C1
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-6751
Mailing Address - Country:US
Mailing Address - Phone:941-391-5495
Mailing Address - Fax:941-875-9875
Practice Address - Street 1:21202 OLEAN BLVD
Practice Address - Street 2:C1
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6751
Practice Address - Country:US
Practice Address - Phone:941-391-5495
Practice Address - Fax:941-875-9875
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA0002743363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE1089SOtherMEDICARE PTAN
FLE1089TOtherMEDICARE PTAN
FLE1089TOtherMEDICARE PTAN