Provider Demographics
NPI:1710684758
Name:SULLIVAN, BENJAMIN JACOB (PA-C)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JACOB
Last Name:SULLIVAN
Suffix:
Gender:M
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 1:3398 LAKE BROOK BLVD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-3708
Mailing Address - Country:US
Mailing Address - Phone:314-640-5425
Mailing Address - Fax:
Practice Address - Street 1:80 VERMONT AVE
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6474
Practice Address - Country:US
Practice Address - Phone:865-482-4078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-09
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ081975Medicaid