Provider Demographics
NPI:1760508329
Name:SULLIVAN, JULIA W (CRNA)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:W
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 STADIUM DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26506-7911
Mailing Address - Country:US
Mailing Address - Phone:304-346-9400
Mailing Address - Fax:304-720-8461
Practice Address - Street 1:1200 J D ANDERSON DR
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3494
Practice Address - Country:US
Practice Address - Phone:304-346-9400
Practice Address - Fax:304-345-7320
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV47812367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD412266600Medicaid
WV1073294OtherWORKERS COMP
PA1019415650001Medicaid
OH2742198Medicaid
WV3810008943Medicaid
WV8242291Medicare PIN
WVSU6035531Medicare PIN