Healthcare Provider Details

I. General information

NPI: 1366678575
Provider Name (Legal Business Name): MARTY MCCULLOUGH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2009
Last Update Date: 02/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 ZEAGLER DR
PALATKA FL
32177-3810
US

IV. Provider business mailing address

PO BOX 3123
ST AUGUSTINE FL
32085-3123
US

V. Phone/Fax

Practice location:
  • Phone: 386-326-7865
  • Fax:
Mailing address:
  • Phone: 904-824-4990
  • Fax: 904-824-2226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP3323342
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: