Provider Demographics
NPI:1326198110
Name:SULLIVAN, LEN (PA)
Entity Type:Individual
Prefix:
First Name:LEN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:305 MALLARD LN
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:TX
Practice Address - Zip Code:76574-1208
Practice Address - Country:US
Practice Address - Phone:512-352-7611
Practice Address - Fax:512-352-2196
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00703363A00000X
MA902363AM0700X
TXPA11712363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical