Provider Demographics
NPI:1306980933
Name:CULLOTTA, ANNA R (PA-C)
Entity type:Individual
Prefix:MS
First Name:ANNA
Middle Name:R
Last Name:CULLOTTA
Suffix:
Gender:F
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 1:1040 SIERRA DR
Mailing Address - Street 2:STE 400
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7241
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:
Practice Address - Street 1:12800 MISSISSIPPI PKWY
Practice Address - Street 2:STE B100
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-9031
Practice Address - Country:US
Practice Address - Phone:219-662-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-003028363AM0700X
IN10001782A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
K510503Medicare PIN
INM14714061Medicare PIN