Individual
MR. CULLEN ANTHONY MACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.A.
Contact information
Practice address
235 E BARNETT RD, SUITE 106, MEDFORD, OR 97501-7901
(541) 773-4029
Mailing address
815 N CENTRAL AVE, SUITE C, MEDFORD, OR 97501-5873
(541) 734-9030
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
180563
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PA180563
MEDICAL LICENSE
—
Enumeration date
11/23/2016
Last updated
03/07/2023
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