Provider Demographics
NPI:1518298249
Name:SULLIVAN, MALIN
Entity Type:Individual
Prefix:
First Name:MALIN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 DEL VALLE
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-9506
Mailing Address - Country:US
Mailing Address - Phone:831-430-6426
Mailing Address - Fax:
Practice Address - Street 1:225 N JACKSON AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1603
Practice Address - Country:US
Practice Address - Phone:408-259-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20730363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant