Provider Demographics
NPI:1760917207
Name:SULLIVAN, TYLER ASHLEY (PA-C)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:ASHLEY
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TYLER
Other - Middle Name:ASHLEY
Other - Last Name:ROSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST STE 520
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4430
Mailing Address - Country:US
Mailing Address - Phone:800-321-9999
Mailing Address - Fax:267-479-1321
Practice Address - Street 1:101 PHEASANT RUN
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-1820
Practice Address - Country:US
Practice Address - Phone:800-321-9999
Practice Address - Fax:267-479-1321
Is Sole Proprietor?:No
Enumeration Date:2017-04-21
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA063056363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant