Provider Demographics
NPI:1053717876
Name:CULOTTA, MARY GENEVIEVE (PA)
Entity type:Individual
Prefix:MISS
First Name:MARY
Middle Name:GENEVIEVE
Last Name:CULOTTA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:GENNY
Other - Middle Name:
Other - Last Name:CULOTTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1717 ST. CHARLES AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70130
Mailing Address - Country:US
Mailing Address - Phone:504-899-2800
Mailing Address - Fax:
Practice Address - Street 1:1514 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70121
Practice Address - Country:US
Practice Address - Phone:504-899-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-05
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200778363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00034366Medicaid
LA2393235Medicaid
LA378432YH3UMedicare PIN