Provider Demographics
NPI:1083298673
Name:SHANROCK, CULLEN RICHARD (DPM)
Entity type:Individual
Prefix:
First Name:CULLEN
Middle Name:RICHARD
Last Name:SHANROCK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7428 LOON LANDING SHRS
Mailing Address - Street 2:
Mailing Address - City:LAKE TOMAHAWK
Mailing Address - State:WI
Mailing Address - Zip Code:54539-9110
Mailing Address - Country:US
Mailing Address - Phone:651-564-2094
Mailing Address - Fax:
Practice Address - Street 1:311 ELM ST
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:WI
Practice Address - Zip Code:54568-9149
Practice Address - Country:US
Practice Address - Phone:651-564-2094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI1339-25213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program