Provider Demographics
NPI:1447800552
Name:MCCULLOUGH, KEITH MICHAEL (PA-C)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:MICHAEL
Last Name:MCCULLOUGH
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:700 W IRONWOOD DR STE 175
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4401
Mailing Address - Country:US
Mailing Address - Phone:208-625-6309
Mailing Address - Fax:208-625-6310
Practice Address - Street 1:700 W IRONWOOD DR STE 175
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4401
Practice Address - Country:US
Practice Address - Phone:208-625-6300
Practice Address - Fax:208-625-6301
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2025-08-03
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Provider Licenses
StateLicense IDTaxonomies
IDPA-1818363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant