Provider Demographics
NPI:1265845374
Name:MCCULLOM, JAMES ANTHONY II
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ANTHONY
Last Name:MCCULLOM
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15624 N 172ND DR
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85388-0239
Mailing Address - Country:US
Mailing Address - Phone:602-576-9957
Mailing Address - Fax:
Practice Address - Street 1:3104 E INDIAN SCHOOL RD
Practice Address - Street 2:#200
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-6889
Practice Address - Country:US
Practice Address - Phone:602-954-9484
Practice Address - Fax:602-954-6433
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist