Provider Demographics
NPI:1033144019
Name:SULLIVAN, MAUREEN (PA-C)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 CHATHAM DR
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-2953
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17 W RED BANK AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-1630
Practice Address - Country:US
Practice Address - Phone:856-845-0664
Practice Address - Fax:856-845-7602
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP000245363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA003234LOtherMEDICAL LICENSE
NJ25MP000245OtherLICENSE
S78130Medicare UPIN