Provider Demographics
NPI:1407056708
Name:SULLIVAN, JOHN THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
Last Name:SULLIVAN
Suffix:
Gender:M
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 1:4811 E GRANT RD STE 261
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2776
Mailing Address - Country:US
Mailing Address - Phone:520-618-1010
Mailing Address - Fax:
Practice Address - Street 1:5670 N PROFESSIONAL PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-7878
Practice Address - Country:US
Practice Address - Phone:520-618-1010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6307363A00000X
MN1652363A00000X
PAMA052973363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ113349Medicaid