Provider Demographics
NPI:1225070923
Name:MCCULLOUGH, MADELAINE CATHLEEN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MADELAINE
Middle Name:CATHLEEN
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:17950 PRESTON RD
Mailing Address - Street 2:STE 250
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75252-5793
Mailing Address - Country:US
Mailing Address - Phone:972-354-5720
Mailing Address - Fax:972-354-5747
Practice Address - Street 1:8419 KERBAUGH RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98516-9349
Practice Address - Country:US
Practice Address - Phone:303-359-1730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2023-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61169119363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO25954555Medicaid
CO811808Medicare PIN
CO25954555Medicaid
CO811808Medicare Oscar/Certification