Healthcare Provider Details

I. General information

NPI: 1528397338
Provider Name (Legal Business Name): BRANDON SCOTT MCCULLEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 05/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 S LAMAR BLVD
OXFORD MS
38655-5373
US

IV. Provider business mailing address

7007 BLUFF LN
OXFORD MS
38655-5968
US

V. Phone/Fax

Practice location:
  • Phone: 662-232-8100
  • Fax:
Mailing address:
  • Phone: 662-816-7871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR883357
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: