Provider Demographics
NPI:1558725176
Name:CULBREATH, JOHN TIMOTHY (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:TIMOTHY
Last Name:CULBREATH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3270 LONGVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-1648
Mailing Address - Country:US
Mailing Address - Phone:650-703-3508
Mailing Address - Fax:
Practice Address - Street 1:2581 SAMARITAN DR STE 202
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-4112
Practice Address - Country:US
Practice Address - Phone:408-358-3939
Practice Address - Fax:408-490-2849
Is Sole Proprietor?:No
Enumeration Date:2016-04-09
Last Update Date:2016-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 14532363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant