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General NPI Number Information
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NPI Number | 1083298673
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Entity Type | Individual
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Provider Name | CULLEN RICHARD SHANROCK DPM
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Gender | Male
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Dates
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Enumeration Date | 05/10/2021
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Last Update Date | 10/01/2024
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Provider Practice Location Address
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Address Line | 311 ELM ST
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City | WOODRUFF
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State | WI
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Zip | 54568-9149
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Country | US
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Telephone | 651-564-2094
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Fax |
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Provider Business Mailing Address
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Address Line | 7428 LOON LANDING SHRS
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City | LAKE TOMAHAWK
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State | WI
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Zip | 54539-9110
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Country | US
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Telephone | 651-564-2094
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 1339-25
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License Number State | WI
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