Provider Demographics
NPI:1013381169
Name:MCCULLUM, PHYLLIS (PA)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:
Last Name:MCCULLUM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 COURT ST
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2733
Mailing Address - Country:US
Mailing Address - Phone:518-562-1080
Mailing Address - Fax:
Practice Address - Street 1:96 COURT ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-2733
Practice Address - Country:US
Practice Address - Phone:518-562-1080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-29
Last Update Date:2015-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant