Provider Demographics
NPI:1639142458
Name:ROWLEY-SULLIVAN, CYNTHIA (PA)
Entity Type:Individual
Prefix:MS
First Name:CYNTHIA
Middle Name:
Last Name:ROWLEY-SULLIVAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 W 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:COAL VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61240-9337
Mailing Address - Country:US
Mailing Address - Phone:309-799-7518
Mailing Address - Fax:309-799-3886
Practice Address - Street 1:104 W 18TH AVE
Practice Address - Street 2:
Practice Address - City:COAL VALLEY
Practice Address - State:IL
Practice Address - Zip Code:61240-9337
Practice Address - Country:US
Practice Address - Phone:309-799-7518
Practice Address - Fax:309-799-3886
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002201363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1639142458Medicaid
IL93342OtherBCWELLMARK NUMBER
ILIL01W4OtherJOHN DEERE NUMBER
IL362739299001OtherTRICARE NUMBER
IL1639142458Medicaid
IL200715014Medicare PIN
IL93342OtherBCWELLMARK NUMBER
IL362739299001OtherTRICARE NUMBER