Provider Demographics
NPI:1629092457
Name:MCCULLOCH, DAVID A (PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:MCCULLOCH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6009 UNITAS CT NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4938
Mailing Address - Country:US
Mailing Address - Phone:505-897-4699
Mailing Address - Fax:
Practice Address - Street 1:1501 SAN PEDRO, SE
Practice Address - Street 2:VA MEDICAL CENTER
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108
Practice Address - Country:US
Practice Address - Phone:505-265-1711
Practice Address - Fax:505-256-5772
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM81-PA015363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical