Healthcare Provider Details

I. General information

NPI: 1265845374
Provider Name (Legal Business Name): JAMES ANTHONY MCCULLOM II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2014
Last Update Date: 06/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3104 E INDIAN SCHOOL RD #200
PHOENIX AZ
85016-6889
US

IV. Provider business mailing address

15624 N 172ND DR
SURPRISE AZ
85388-0239
US

V. Phone/Fax

Practice location:
  • Phone: 602-954-9484
  • Fax: 602-954-6433
Mailing address:
  • Phone: 602-576-9957
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: