Provider Demographics
NPI:1427569623
Name:SULLIVAN, PATRICK LEWIS
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:LEWIS
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7180 S REDWATER DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85757-6938
Mailing Address - Country:US
Mailing Address - Phone:520-838-4200
Mailing Address - Fax:
Practice Address - Street 1:7180 S REDWATER DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85757-6938
Practice Address - Country:US
Practice Address - Phone:520-838-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZL14658028343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ943433561Medicaid