Provider Demographics
NPI:1639659733
Name:SULLIVAN, KACEY (PA-C)
Entity Type:Individual
Prefix:
First Name:KACEY
Middle Name:
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 1:830 SW MULVANE ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-1654
Mailing Address - Country:US
Mailing Address - Phone:785-270-8625
Mailing Address - Fax:785-270-8624
Practice Address - Street 1:830 SW MULVANE ST
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-1654
Practice Address - Country:US
Practice Address - Phone:785-270-8625
Practice Address - Fax:785-270-8624
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61190646363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical