1225510779 NPI number — MORGAN MCCULLOUGH WOMBOLDT AGACNP

Table of content: MORGAN MCCULLOUGH WOMBOLDT AGACNP (NPI 1225510779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225510779 NPI number — MORGAN MCCULLOUGH WOMBOLDT AGACNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOMBOLDT
Provider First Name:
MORGAN
Provider Middle Name:
MCCULLOUGH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AGACNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCCULLOUGH
Provider Other First Name:
MORGAN
Provider Other Middle Name:
LANE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
AGACNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1225510779
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6130 JASMINE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32504-7624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-422-5744
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1635 NORTH LOOP W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77008-1532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-867-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  AP138039 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)