Provider Demographics
NPI:1073074332
Name:SULLIVAN, ASIA JASMINE (PA-C)
Entity Type:Individual
Prefix:
First Name:ASIA
Middle Name:JASMINE
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 1:3514 7TH CT S APT 1
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35222-3239
Mailing Address - Country:US
Mailing Address - Phone:251-597-5774
Mailing Address - Fax:
Practice Address - Street 1:5901 W OLYMPIC BLVD STE 401
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4669
Practice Address - Country:US
Practice Address - Phone:310-651-9017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56580363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty