Provider Demographics
NPI:1366678575
Name:MCCULLOUGH, MARTY (CRNA)
Entity Type:Individual
Prefix:
First Name:MARTY
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3123
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-3123
Mailing Address - Country:US
Mailing Address - Phone:904-824-4990
Mailing Address - Fax:904-824-2226
Practice Address - Street 1:611 ZEAGLER DR
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3810
Practice Address - Country:US
Practice Address - Phone:386-326-7865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-02
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3323342367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002134100Medicaid
FLG00CFOtherBCBS
FLDF898ZMedicare PIN