Healthcare Provider Details

I. General information

NPI: 1942061650
Provider Name (Legal Business Name): KATHRYN CULLUM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2024
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5433 W WALSH LN
ROGERS AR
72758-8946
US

IV. Provider business mailing address

105 JENNA LN
GRAVETTE AR
72736-5019
US

V. Phone/Fax

Practice location:
  • Phone: 479-777-8014
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-1242
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: