Provider Demographics
NPI:1477592988
Name:SULLIVAN, SCOTT F (PA)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:F
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 DUDLEY ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-2403
Mailing Address - Country:US
Mailing Address - Phone:401-273-4155
Mailing Address - Fax:401-272-1456
Practice Address - Street 1:118 DUDLEY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-2403
Practice Address - Country:US
Practice Address - Phone:401-273-4155
Practice Address - Fax:401-273-4115
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00259363A00000X
RI00259363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS36567Medicare UPIN
MAS36567Medicare UPIN