Provider Demographics
NPI:1902878945
Name:MCCULLEN, DAVID GARRET (CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:GARRET
Last Name:MCCULLEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2819
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-6600
Mailing Address - Country:US
Mailing Address - Phone:662-550-4299
Mailing Address - Fax:662-580-4324
Practice Address - Street 1:303 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606-8608
Practice Address - Country:US
Practice Address - Phone:662-563-0155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2017-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR876450367500000X
ARC01579367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02537897Medicaid
MS302I431986Medicare PIN