Provider Demographics
NPI:1851121644
Name:MCCULLOUGH, BRANDON
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3134 PLAZA DR NE APT A16
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-2942
Mailing Address - Country:US
Mailing Address - Phone:616-322-8463
Mailing Address - Fax:
Practice Address - Street 1:261 N MAIN
Practice Address - Street 2:
Practice Address - City:CEDAR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49319-8041
Practice Address - Country:US
Practice Address - Phone:616-696-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical