Provider Demographics
NPI:1104824911
Name:MCCULLOUGH, VERNON R (CRNA)
Entity Type:Individual
Prefix:
First Name:VERNON
Middle Name:R
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:214-590-4105
Mailing Address - Fax:214-590-4162
Practice Address - Street 1:5201 HARRY HINES BLVD
Practice Address - Street 2:DEPT. OF ANESTHESIOLOGY
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7708
Practice Address - Country:US
Practice Address - Phone:214-590-8329
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX583555367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX87567HMedicare ID - Type Unspecified00C17N
TXP54768Medicare UPIN