Provider Demographics
NPI:1740205863
Name:SULLIVAN, MICHAEL L (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:1540 S TAMIAMI TRL
Practice Address - Street 2:SUITE 303
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2930
Practice Address - Country:US
Practice Address - Phone:941-917-8791
Practice Address - Fax:941-917-8793
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3485363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY00N0OtherBCBS
FL261645900Medicaid
SC1154PAMedicaid
NC2745040AMedicare PIN
FLE1733XMedicare PIN
FLY00N0OtherBCBS