Basic Information
| Provider Information | |||||||||
| NPI: | 1285147793 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCULLOUGH | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 PARK RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282092290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043232237 | ||||||||
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| Practice Location | |||||||||
| Address1: | 197 PIEDMONT BLVD STE 111 | ||||||||
| Address2: | |||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297321825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033286306 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2017 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-07689 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 4394 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 3507PA | 05 | SC | MEDICAID | 1285147793 | 05 | NC | MEDICAID |