Provider Demographics
NPI:1073859732
Name:CULBERTSON, JOHN COLIN (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:COLIN
Last Name:CULBERTSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-0996
Practice Address - Street 1:1460 E BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:SUITE 700
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5644
Practice Address - Country:US
Practice Address - Phone:318-681-5580
Practice Address - Fax:318-681-5280
Is Sole Proprietor?:No
Enumeration Date:2012-12-27
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200663363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA546995YJBAMedicare PIN