Provider Demographics
NPI:1194822650
Name:MACCULLOCH, PATRICIA A (NP)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:A
Last Name:MACCULLOCH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 BELMONT ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:119 BELMONT STREET
Practice Address - Street 2:SPINCE CENTER
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605
Practice Address - Country:US
Practice Address - Phone:508-334-1886
Practice Address - Fax:508-334-9769
Is Sole Proprietor?:No
Enumeration Date:2006-09-19
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA241024363L00000X
MARN241024363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110074517AMedicaid
Q74236Medicare UPIN
MANP5524Medicare PIN