Provider Demographics
NPI:1427044577
Name:O'SULLIVAN, CORMAC T (CRNA)
Entity Type:Individual
Prefix:
First Name:CORMAC
Middle Name:T
Last Name:O'SULLIVAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-2633
Mailing Address - Fax:319-356-2940
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-356-2633
Practice Address - Fax:319-356-2940
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD079986367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA56625OtherWELLMARK BCBS
IA0146480Medicaid
IA0146480Medicaid
IA56625OtherWELLMARK BCBS