Provider Demographics
NPI:1033457395
Name:MID-COLUMBIA DERMATOLOGY, LLC
Entity Type:Organization
Organization Name:MID-COLUMBIA DERMATOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-619-5936
Mailing Address - Street 1:309 BRADLEY BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-4381
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:309 BRADLEY BLVD
Practice Address - Street 2:STE 101
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-4381
Practice Address - Country:US
Practice Address - Phone:509-619-5936
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-22
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60140231363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty