Provider Demographics
NPI:1851410138
Name:MCCULLOUGH, MEGAN A (NP-C)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:A
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2141 SAINT ALBANS ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1224
Mailing Address - Country:US
Mailing Address - Phone:484-431-4887
Mailing Address - Fax:
Practice Address - Street 1:111 S 11TH ST
Practice Address - Street 2:SUITE 6270
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4824
Practice Address - Country:US
Practice Address - Phone:215-955-4912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009159363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103187087Medicaid
PA103187087Medicaid