Provider Demographics
NPI:1740976786
Name:PUTNEY, CULLAN FORREST
Entity type:Individual
Prefix:
First Name:CULLAN
Middle Name:FORREST
Last Name:PUTNEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 WOOTTON PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-1066
Mailing Address - Country:US
Mailing Address - Phone:240-453-6000
Mailing Address - Fax:
Practice Address - Street 1:13777 AIR EXPRESSWAY BLVD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394-0510
Practice Address - Country:US
Practice Address - Phone:760-530-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-13
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty