Provider Demographics
NPI:1962043729
Name:CULLEY, BRIAN MICHAEL
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:MICHAEL
Last Name:CULLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10223 STATHOS DR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-5995
Mailing Address - Country:US
Mailing Address - Phone:530-262-3484
Mailing Address - Fax:
Practice Address - Street 1:10423 OLD PLACERVILLE RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95827-2540
Practice Address - Country:US
Practice Address - Phone:167-375-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012230363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily