Provider Demographics
NPI:1821662719
Name:MCCULLOUGH, BRYAN (NP)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 HAYWARD RD
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-3004
Mailing Address - Country:US
Mailing Address - Phone:978-855-0328
Mailing Address - Fax:
Practice Address - Street 1:41 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:MA
Practice Address - Zip Code:01890-1496
Practice Address - Country:US
Practice Address - Phone:781-729-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2259511363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care