Provider Demographics
NPI:1043622525
Name:CANSLER, COLT ALLEN (PA-C)
Entity type:Individual
Prefix:
First Name:COLT
Middle Name:ALLEN
Last Name:CANSLER
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 1:330 N WABASH AVE STE G-20
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2605
Mailing Address - Country:US
Mailing Address - Phone:765-660-7616
Mailing Address - Fax:765-651-7313
Practice Address - Street 1:1130 N BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2536
Practice Address - Country:US
Practice Address - Phone:765-660-7480
Practice Address - Fax:765-382-4495
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99062293A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300016910Medicaid
IN000001216651OtherANTHEM