Provider Demographics
NPI:1306243803
Name:CULLEN ARCHER, MD, PLLC
Entity type:Organization
Organization Name:CULLEN ARCHER, MD, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CULLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ARCHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-830-5100
Mailing Address - Street 1:992 E BROOKFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:ERDA
Mailing Address - State:UT
Mailing Address - Zip Code:84074-3304
Mailing Address - Country:US
Mailing Address - Phone:435-830-5100
Mailing Address - Fax:
Practice Address - Street 1:3651 N 100 E
Practice Address - Street 2:SUITE 375
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-4597
Practice Address - Country:US
Practice Address - Phone:435-830-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7359472-1205207V00000X
UT6814504-1206363A00000X
UT7257858-1205207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty