Healthcare Provider Details

I. General information

NPI: 1902598568
Provider Name (Legal Business Name): KORY MCCULLAH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2023
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11050 MT BELVEDERE BLVD
FORT DRUM NY
13602-2603
US

IV. Provider business mailing address

5187 STATE HIGHWAY 56
COLTON NY
13625-7785
US

V. Phone/Fax

Practice location:
  • Phone: 315-774-2359
  • Fax:
Mailing address:
  • Phone: 907-799-9792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: