Provider Demographics
NPI:1639383219
Name:SULLIVAN, URSULA LYNELL (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:URSULA
Middle Name:LYNELL
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2046 MERCURY DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-7115
Mailing Address - Country:US
Mailing Address - Phone:252-752-0230
Mailing Address - Fax:
Practice Address - Street 1:2100 STANTONSBURG RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-2818
Practice Address - Country:US
Practice Address - Phone:252-847-3040
Practice Address - Fax:252-847-3472
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101547363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCR39705Medicare UPIN