Provider Demographics
NPI:1326023433
Name:SULLIVAN, KATHY M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
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 1:300 STATE ST
Mailing Address - Street 2:#400A
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1427
Mailing Address - Country:US
Mailing Address - Phone:814-454-8287
Mailing Address - Fax:814-454-8470
Practice Address - Street 1:300 STATE ST
Practice Address - Street 2:#400A
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1427
Practice Address - Country:US
Practice Address - Phone:814-454-8287
Practice Address - Fax:814-454-8470
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002986L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S84187Medicare UPIN
028636J7MMedicare ID - Type Unspecified