Provider Demographics
NPI:1265071211
Name:MCCULLOUGH, WHITNEY MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:WHITNEY
Middle Name:MARIE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:WHITNEY
Other - Middle Name:M
Other - Last Name:WARNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6220 MANATEE AVE W STE 201
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-2361
Mailing Address - Country:US
Mailing Address - Phone:417-924-1519
Mailing Address - Fax:
Practice Address - Street 1:6220 MANATEE AVE W STE 201
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-2361
Practice Address - Country:US
Practice Address - Phone:941-792-4151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-21
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363A00000X
FLPA9114546363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant