Basic Information
| Provider Information | |||||||||
| NPI: | 1124322425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CULLEN | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 955 HOSFORD RD | ||||||||
| Address2: | |||||||||
| City: | GALION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448339325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194680935 | ||||||||
| FaxNumber: | 4194625372 | ||||||||
| Practice Location | |||||||||
| Address1: | 955 HOSFORD RD | ||||||||
| Address2: | |||||||||
| City: | GALION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194687059 | ||||||||
| FaxNumber: | 4194686962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2010 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0084962 | 05 | OH | MEDICAID |