Provider Demographics
NPI:1225510779
Name:WOMBOLDT, MORGAN MCCULLOUGH (AGACNP)
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:MCCULLOUGH
Last Name:WOMBOLDT
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:MORGAN
Other - Middle Name:LANE
Other - Last Name:MCCULLOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGACNP
Mailing Address - Street 1:6130 JASMINE RD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-7624
Mailing Address - Country:US
Mailing Address - Phone:251-422-5744
Mailing Address - Fax:
Practice Address - Street 1:1635 NORTH LOOP W
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-1532
Practice Address - Country:US
Practice Address - Phone:713-867-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-31
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP138039363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care