Provider Demographics
NPI:1679694749
Name:SULLIVAN, MARY ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 N NORTHGATE WAY
Mailing Address - Street 2:#217
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133
Mailing Address - Country:US
Mailing Address - Phone:206-363-2136
Mailing Address - Fax:206-363-0523
Practice Address - Street 1:2111 N NORTHGATE WAY
Practice Address - Street 2:#217
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133
Practice Address - Country:US
Practice Address - Phone:206-363-2136
Practice Address - Fax:206-363-0523
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00015257207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1619709Medicaid
A14988Medicare UPIN