Healthcare Provider Details

I. General information

NPI: 1629092457
Provider Name (Legal Business Name): DAVID A MCCULLOCH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO, SE VA MEDICAL CENTER
ALBUQUERQUE NM
87108
US

IV. Provider business mailing address

6009 UNITAS CT NW
ALBUQUERQUE NM
87114-4938
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax: 505-256-5772
Mailing address:
  • Phone: 505-897-4699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number81-PA015
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: