Provider Demographics
NPI:1376870097
Name:SULLIVAN, PATRICIA (PA-C)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
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 1:4400 N 32ND ST
Mailing Address - Street 2:STE 220
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-3953
Mailing Address - Country:US
Mailing Address - Phone:602-956-1250
Mailing Address - Fax:602-956-7466
Practice Address - Street 1:4400 N 32ND ST
Practice Address - Street 2:STE 220
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-3953
Practice Address - Country:US
Practice Address - Phone:602-956-1250
Practice Address - Fax:602-956-7466
Is Sole Proprietor?:No
Enumeration Date:2009-11-17
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4531363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4531OtherPA LIC
AZ483070Medicaid