Provider Demographics
NPI:1619152915
Name:SULLIVAN, TIMOTHY MARK (PA)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:MARK
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 1:5432 E SOUTHERN AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-2772
Mailing Address - Country:US
Mailing Address - Phone:480-325-3275
Mailing Address - Fax:480-981-9123
Practice Address - Street 1:9951 E EL MORO AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85208-5869
Practice Address - Country:US
Practice Address - Phone:602-570-6428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-04
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ122257Medicare PIN