Provider Demographics
NPI:1336560051
Name:MCCULLOUGH, KIRSTEN JEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:JEAN
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6801 W 20TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-9637
Mailing Address - Country:US
Mailing Address - Phone:970-378-8000
Mailing Address - Fax:970-378-8088
Practice Address - Street 1:6801 W 20TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-9637
Practice Address - Country:US
Practice Address - Phone:970-378-8000
Practice Address - Fax:970-378-8088
Is Sole Proprietor?:No
Enumeration Date:2013-12-23
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3883363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPA.0003883OtherCO STATE BOARD