Basic Information
| Provider Information | |||||||||
| NPI: | 1679771497 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CULLEN | ||||||||
| FirstName: | ETHANY | ||||||||
| MiddleName: | LEA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11995 SINGLETREE LN | ||||||||
| Address2: | STE 500 | ||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553445347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525951301 | ||||||||
| FaxNumber: | 6122944903 | ||||||||
| Practice Location | |||||||||
| Address1: | 421 12TH ST NW | ||||||||
| Address2: | |||||||||
| City: | BYRON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559201391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525951100 | ||||||||
| FaxNumber: | 6122944903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2007 | ||||||||
| LastUpdateDate: | 05/22/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 51214 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.