Provider Demographics
NPI:1225075328
Name:SULLIVAN, MARK C (PA-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:SULLIVAN
Suffix:
Gender:M
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 1:333 BORTHWICK AVENUE
Mailing Address - Street 2:SUITE 402
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801
Mailing Address - Country:US
Mailing Address - Phone:603-559-4111
Mailing Address - Fax:603-559-4110
Practice Address - Street 1:333 BORTHWICK AVENUE
Practice Address - Street 2:SUITE 402
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801
Practice Address - Country:US
Practice Address - Phone:603-559-4111
Practice Address - Fax:603-663-6822
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA 880363AS0400X
NH0238P363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3076816Medicaid
NHS14421Medicare UPIN
NHRAILROAD P01434673Medicare PIN
NH3076816Medicaid
MEAP069002Medicare PIN
MEAP069002Medicare PIN
NHP00128507Medicare PIN