Healthcare Provider Details

I. General information

NPI: 1780676866
Provider Name (Legal Business Name): PATRICIA E MCCULLOCH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 11/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 GALISTEO ST SUITE 8
SANTA FE NM
87505-4752
US

IV. Provider business mailing address

1651 GALISTEO ST SUITE 8
SANTA FE NM
87505-4752
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-9870
  • Fax: 505-983-1265
Mailing address:
  • Phone: 505-820-9870
  • Fax: 505-983-1265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-059
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2004-0017
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: