Provider Demographics
NPI:1750923538
Name:MCCULLOUGH, SAMUEL SCOTT III (FNP-C)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:SCOTT
Last Name:MCCULLOUGH
Suffix:III
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 HUBER ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6983
Mailing Address - Country:US
Mailing Address - Phone:601-260-9830
Mailing Address - Fax:
Practice Address - Street 1:120 FOUNTAINS BLVD # 1000
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-6343
Practice Address - Country:US
Practice Address - Phone:763-300-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-12
Last Update Date:2019-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903614363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty