Provider Demographics
NPI:1538676226
Name:SULLIVAN, JOSEPH SULLIVAN EDWARD (PTA)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH SULLIVAN
Middle Name:EDWARD
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1656 BREWER RD
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-9787
Mailing Address - Country:US
Mailing Address - Phone:315-749-6769
Mailing Address - Fax:
Practice Address - Street 1:249 GLENWOOD RD
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-1603
Practice Address - Country:US
Practice Address - Phone:607-240-4828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-04
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007413225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant