Provider Demographics
NPI:1053424598
Name:CULLER, MICHAEL DEAN (PA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:DEAN
Last Name:CULLER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 W LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-2954
Mailing Address - Country:US
Mailing Address - Phone:336-789-9492
Mailing Address - Fax:336-789-9587
Practice Address - Street 1:414 W LEBANON ST
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-2954
Practice Address - Country:US
Practice Address - Phone:336-789-9492
Practice Address - Fax:336-789-9587
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004396363A00000X
NC101079363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VADN2980OtherGROUP PTAN
NC1053424598Medicaid
NC2760137OtherMEDICARE
261083931OtherTAX ID
VA1053424598Medicaid
VAP01130746OtherPTAN
NC153YKOtherBCBS NC