Provider Demographics
NPI:1184189425
Name:MCCULLOUGH, MATHEW R (PA-C)
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:R
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 529
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:CO
Mailing Address - Zip Code:81425-0529
Mailing Address - Country:US
Mailing Address - Phone:970-323-6141
Mailing Address - Fax:855-299-8071
Practice Address - Street 1:1250 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-3138
Practice Address - Country:US
Practice Address - Phone:970-874-8981
Practice Address - Fax:855-299-7586
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-31
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006103207Q00000X, 363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine