Provider Demographics
NPI:1306205885
Name:BRUZATORI, MICHELLE SULLIVAN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SULLIVAN
Last Name:BRUZATORI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:REGAN
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2037 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CABOT
Mailing Address - State:AR
Mailing Address - Zip Code:72023-7479
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2037 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-7479
Practice Address - Country:US
Practice Address - Phone:501-843-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT2016-009363A00000X
ARPA-645363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant