Provider Demographics
NPI:1629294947
Name:MCCULLOHS, STACI HAGGERTY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:STACI
Middle Name:HAGGERTY
Last Name:MCCULLOHS
Suffix:
Gender:F
Credentials:PA-C
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:975 JOHNSON FERRY RD NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342
Mailing Address - Country:US
Mailing Address - Phone:404-256-1311
Mailing Address - Fax:404-303-9798
Practice Address - Street 1:975 JOHNSON FERRY RD NE
Practice Address - Street 2:SUITE 100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-256-2157
Practice Address - Fax:404-303-9798
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2016-11-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA005021363A00000X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant