Provider Demographics
NPI:1700023348
Name:SULLIVAN, MARK MONTOGOMERY (PAC, MPAS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:MONTOGOMERY
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PAC, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2609 OAK CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-6522
Mailing Address - Country:US
Mailing Address - Phone:801-244-2834
Mailing Address - Fax:
Practice Address - Street 1:5121 COTTONWOOD ST
Practice Address - Street 2:SUITE 320
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5701
Practice Address - Country:US
Practice Address - Phone:801-507-3380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-20
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7131889-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant