Provider Demographics
NPI: | 1932147592 |
---|---|
Name: | PULVER, RHONDA (PA) |
Entity Type: | Individual |
Prefix: | |
First Name: | RHONDA |
Middle Name: | |
Last Name: | PULVER |
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: | 18209 EULA MAE PKWY |
Mailing Address - Street 2: | |
Mailing Address - City: | CARLYLE |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 62231-6407 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 618-594-3671 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 18209 EULA MAE PKWY |
Practice Address - Street 2: | |
Practice Address - City: | CARLYLE |
Practice Address - State: | IL |
Practice Address - Zip Code: | 62231-6407 |
Practice Address - Country: | US |
Practice Address - Phone: | 618-594-3671 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-03 |
Last Update Date: | 2015-12-07 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 5601004526 | 363A00000X |
IL | 085003220 | 363AM0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | IL4903003 | Medicare PIN | |
MI | N94880004 | Medicare ID - Type Unspecified |