Provider Demographics
NPI:1760412084
Name:SULLIVAN, TIMOTHY FRANCIS (MS, PA-C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:FRANCIS
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 BOSTON PROVIDENCE TPKE
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-5061
Mailing Address - Country:US
Mailing Address - Phone:781-255-0500
Mailing Address - Fax:781-255-0400
Practice Address - Street 1:1210 BOSTON PROVIDENCE TPKE
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-5061
Practice Address - Country:US
Practice Address - Phone:781-255-0500
Practice Address - Fax:781-255-0400
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00358363A00000X
MAPA4234363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400140917Medicare PIN