Individual
RYAN T MCCULLOCH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
147 W CHUBBUCK RD, CHUBBUCK, ID 83202-2314
(208) 238-7546
(208) 237-9643
Mailing address
147 W CHUBBUCK RD, CHUBBUCK, ID 83202-2314
(208) 238-7546
(208) 237-9643
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA405
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
806497600
—
ID
01
—
P00329828
RAILROAD MEDICARE PTAN
ID
Enumeration date
08/25/2006
Last updated
12/20/2010
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