Provider Demographics
NPI:1750939922
Name:CULLEN, MICHAEL THOMAS (CRNA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:THOMAS
Last Name:CULLEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 JEWEL LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-1266
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2525 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4518
Practice Address - Country:US
Practice Address - Phone:763-370-0699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2005511163WC0200X
MN2370367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine