Provider Demographics
NPI:1780676866
Name:MCCULLOCH, PATRICIA E (PA-C)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:E
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1651 GALISTEO ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4752
Mailing Address - Country:US
Mailing Address - Phone:505-820-9870
Mailing Address - Fax:505-983-1265
Practice Address - Street 1:1651 GALISTEO ST
Practice Address - Street 2:SUITE 8
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4752
Practice Address - Country:US
Practice Address - Phone:505-820-9870
Practice Address - Fax:505-983-1265
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMPA-059363AM0700X
NMPA2004-0017363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ15416Medicare UPIN