Provider Demographics
NPI:1720195530
Name:MCCULLOCH, RYAN T (PA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:T
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 1:147 W CHUBBUCK RD
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2314
Mailing Address - Country:US
Mailing Address - Phone:208-238-7546
Mailing Address - Fax:208-237-9643
Practice Address - Street 1:147 W CHUBBUCK RD
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2314
Practice Address - Country:US
Practice Address - Phone:208-238-7546
Practice Address - Fax:208-237-9643
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA405363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP00329828OtherRAILROAD MEDICARE PTAN
ID806497600Medicaid
ID806497600Medicaid