Provider Demographics
NPI:1134132632
Name:SULLWOLD, PATRICIA JEAN (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:JEAN
Last Name:SULLWOLD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 15TH ST NW
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-5506
Mailing Address - Country:US
Mailing Address - Phone:651-631-0462
Mailing Address - Fax:
Practice Address - Street 1:1 VETERANS DR
Practice Address - Street 2:VETERANS AFFAIRS MEDICAL CENTER
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-2309
Practice Address - Country:US
Practice Address - Phone:612-725-2158
Practice Address - Fax:612-725-2118
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN030530207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN