Healthcare Provider Details

I. General information

NPI: 1164055505
Provider Name (Legal Business Name): ANNE ELIZABETH CULLEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNE ELIZABETH VASTERLING PA-C

II. Dates (important events)

Enumeration Date: 02/13/2020
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 COUNTY ROAD 120
SAINT CLOUD MN
56303-4872
US

IV. Provider business mailing address

2829 CHURCHILL ST
ROSEVILLE MN
55113-2044
US

V. Phone/Fax

Practice location:
  • Phone: 320-202-8949
  • Fax: 320-257-1733
Mailing address:
  • Phone: 651-787-0878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number13266
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: