Provider Demographics
NPI:1346212966
Name:SULLY, LOUIS (PA)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:
Last Name:SULLY
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 1:720 N 129TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-6109
Mailing Address - Country:US
Mailing Address - Phone:402-397-0670
Mailing Address - Fax:402-397-0713
Practice Address - Street 1:720 N 129TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-6109
Practice Address - Country:US
Practice Address - Phone:402-397-0670
Practice Address - Fax:402-397-0713
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE895363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE272691Medicare ID - Type Unspecified