Provider Demographics
NPI:1942061650
Name:CULLUM, KATHRYN (PA-C)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:CULLUM
Suffix:
Gender:F
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 1:105 JENNA LN
Mailing Address - Street 2:
Mailing Address - City:GRAVETTE
Mailing Address - State:AR
Mailing Address - Zip Code:72736-5019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5433 W WALSH LN
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8946
Practice Address - Country:US
Practice Address - Phone:479-777-8014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-19
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-1242363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical