Healthcare Provider Details

I. General information

NPI: 1528454949
Provider Name (Legal Business Name): LAUREN NOLAND MCCULLOUGH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANE LAUREN NOLAND MARJON

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8020 CONSTITUTION PL NE STE 202
ALBUQUERQUE NM
87110-7640
US

IV. Provider business mailing address

8020 CONSTITUTION PL NE STE 202
ALBUQUERQUE NM
87110-7640
US

V. Phone/Fax

Practice location:
  • Phone: 505-998-3096
  • Fax: 505-998-3100
Mailing address:
  • Phone: 505-998-3096
  • Fax: 505-998-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD2020-0397
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: