Provider Demographics
NPI:1225057151
Name:MCCULLOUGH, BARRY G (PA)
Entity Type:Individual
Prefix:MR
First Name:BARRY
Middle Name:G
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 KINGSLEY AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-5129
Mailing Address - Country:US
Mailing Address - Phone:904-272-7500
Mailing Address - Fax:904-272-7502
Practice Address - Street 1:2140 KINGSLEY AVE STE 1
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5129
Practice Address - Country:US
Practice Address - Phone:904-272-7500
Practice Address - Fax:904-272-7502
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1751363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2908077-00Medicaid
FLE0622ZMedicare PIN
FL970015731Medicare PIN
FL2908077-00Medicaid