Provider Demographics
NPI:1386825909
Name:SULLIVAN, CHARISE N (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARISE
Middle Name:N
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 1:8325 BROADWAY ST
Mailing Address - Street 2:STE 202 283
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581
Mailing Address - Country:US
Mailing Address - Phone:832-870-3730
Mailing Address - Fax:281-258-4592
Practice Address - Street 1:500 E MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598
Practice Address - Country:US
Practice Address - Phone:281-332-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10356363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant