Provider Demographics
NPI:1225196652
Name:SULLIVAN, BENJAMIN ALEXANDER (PA-C)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ALEXANDER
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:P.O. BOX 21182
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228
Mailing Address - Country:US
Mailing Address - Phone:410-368-8640
Mailing Address - Fax:410-368-8644
Practice Address - Street 1:900 CATON AVENUE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229
Practice Address - Country:US
Practice Address - Phone:410-368-2514
Practice Address - Fax:410-368-2640
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003370363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant