Healthcare Provider Details

I. General information

NPI: 1679771497
Provider Name (Legal Business Name): ETHANY LEA CULLEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 05/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 12TH ST NW
BYRON MN
55920-1391
US

IV. Provider business mailing address

11995 SINGLETREE LN STE 500
EDEN PRAIRIE MN
55344-5347
US

V. Phone/Fax

Practice location:
  • Phone: 952-595-1100
  • Fax: 612-294-4903
Mailing address:
  • Phone: 952-595-1301
  • Fax: 612-294-4903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number51214
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: