Provider Demographics
NPI:1982606638
Name:CULBRETH, DANIEL ANDREW (PA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:ANDREW
Last Name:CULBRETH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3787 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6148
Mailing Address - Country:US
Mailing Address - Phone:910-332-3800
Mailing Address - Fax:910-763-8804
Practice Address - Street 1:2716 ASHTON DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2489
Practice Address - Country:US
Practice Address - Phone:910-332-3800
Practice Address - Fax:910-763-8804
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101790363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC101790OtherMEDICAL LICENSE
NC2743217DMedicare PIN
NC101790OtherMEDICAL LICENSE
NC2743217Medicare ID - Type UnspecifiedMEDICARE