Provider Demographics
NPI:1073885323
Name:SULLIVAN, MONICA A (PA-C)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:A
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 1:14421 DUPONT CT
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-2100
Mailing Address - Country:US
Mailing Address - Phone:402-884-6400
Mailing Address - Fax:
Practice Address - Street 1:14421 DUPONT CT
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-2100
Practice Address - Country:US
Practice Address - Phone:402-884-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NE1639363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE91177983213Medicaid
NE91177983213Medicaid