Provider Demographics
NPI:1821046921
Name:SULLIVAN, MARK (PA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
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 1:4 PALISADES DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-1449
Mailing Address - Country:US
Mailing Address - Phone:518-591-1121
Mailing Address - Fax:
Practice Address - Street 1:1 TALLOW WOOD DR
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-2807
Practice Address - Country:US
Practice Address - Phone:518-373-4444
Practice Address - Fax:518-373-0663
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004099363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02347280Medicaid
NYPA0919Medicare PIN
NY02347280Medicaid
NYPA0363Medicare PIN