Provider Demographics
NPI:1326575952
Name:SULLIVAN, LEE RICHARD (AGNPC-AG)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:RICHARD
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:AGNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1765 OLD WEST BROAD ST BLDG 2-200
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2887
Mailing Address - Country:US
Mailing Address - Phone:706-549-1663
Mailing Address - Fax:706-546-8792
Practice Address - Street 1:1765 OLD WEST BROAD ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2853
Practice Address - Country:US
Practice Address - Phone:706-549-1663
Practice Address - Fax:706-546-8792
Is Sole Proprietor?:No
Enumeration Date:2017-05-14
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN213335363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
14182507OtherCAQH NUMBER