Provider Demographics
NPI:1104369099
Name:MACK, CULLEN ANTHONY (PA)
Entity Type:Individual
Prefix:MR
First Name:CULLEN
Middle Name:ANTHONY
Last Name:MACK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 N CENTRAL AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-5873
Mailing Address - Country:US
Mailing Address - Phone:541-734-9030
Mailing Address - Fax:
Practice Address - Street 1:235 E BARNETT RD
Practice Address - Street 2:SUITE 106
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-7901
Practice Address - Country:US
Practice Address - Phone:541-773-4029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR180563363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA180563OtherMEDICAL LICENSE
MM4142890OtherDEA
MM4142890OtherDEA