Provider Demographics
NPI:1992380455
Name:MCCULLOUGH, RYAN DANIEL (PTA)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:DANIEL
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:291 EMERSON DR.
Mailing Address - Street 2:
Mailing Address - City:VIOLET HILL
Mailing Address - State:AR
Mailing Address - Zip Code:72584
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75 INDUSTRIAL DRIVE
Practice Address - Street 2:
Practice Address - City:ASH FLAT
Practice Address - State:AR
Practice Address - Zip Code:72513
Practice Address - Country:US
Practice Address - Phone:501-352-6105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4615225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty