Individual
KEVIN MICHAEL MCCULLOUGH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
601 S SUTTON RD, STE 101, FORT NILL, SC 29715
(803) 328-6306
(803) 909-6451
Mailing address
4601 PARK RD STE 300, CHARLOTTE, NC 28209-2290
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
0010-07689
NC
363A00000X
Physician Assistant
Primary
4394
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1285147793
—
NC
05
—
3507PA
—
SC
Enumeration date
11/07/2017
Last updated
10/20/2023
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