Provider Demographics
NPI:1902598568
Name:MCCULLAH, KORY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KORY
Middle Name:
Last Name:MCCULLAH
Suffix:
Gender:M
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 1:50 IDLEWILD RD
Mailing Address - Street 2:
Mailing Address - City:MARLBORO
Mailing Address - State:NY
Mailing Address - Zip Code:12542-5533
Mailing Address - Country:US
Mailing Address - Phone:907-799-9792
Mailing Address - Fax:
Practice Address - Street 1:50 IDLEWILD RD
Practice Address - Street 2:
Practice Address - City:MARLBORO
Practice Address - State:NY
Practice Address - Zip Code:12542-5533
Practice Address - Country:US
Practice Address - Phone:907-799-9792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1208115363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant