Provider Demographics
NPI:1205005311
Name:SULLIVAN, DEBRA DOVER (PA)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:DOVER
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 12143
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85318-2143
Mailing Address - Country:US
Mailing Address - Phone:623-332-1872
Mailing Address - Fax:623-547-1899
Practice Address - Street 1:14044 W CAMELBACK RD
Practice Address - Street 2:SUITE 118
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-9428
Practice Address - Country:US
Practice Address - Phone:623-547-2600
Practice Address - Fax:623-547-1899
Is Sole Proprietor?:No
Enumeration Date:2008-02-22
Last Update Date:2013-06-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ1622363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP29950Medicare UPIN