Provider Demographics
NPI:1043240328
Name:SULLIVAN, JO M (NP)
Entity Type:Individual
Prefix:
First Name:JO
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 S. 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85723
Mailing Address - Country:US
Mailing Address - Phone:520-629-1838
Mailing Address - Fax:520-629-1773
Practice Address - Street 1:3601 S. 6TH AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85723
Practice Address - Country:US
Practice Address - Phone:520-629-1838
Practice Address - Fax:520-629-1773
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ105958363L00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ864357Medicaid
AZ864357Medicaid
Q18086Medicare UPIN