Provider Demographics
NPI:1821098104
Name:SULLIVAN, MICHAEL J (MS, PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:J
Last Name:SULLIVAN
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Gender:M
Credentials:MS, PA-C
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Mailing Address - Street 1:112 S JONES BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-2614
Mailing Address - Country:US
Mailing Address - Phone:702-838-7110
Mailing Address - Fax:702-838-7112
Practice Address - Street 1:112 S JONES BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-2614
Practice Address - Country:US
Practice Address - Phone:702-838-7110
Practice Address - Fax:702-838-7112
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2010-09-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NVPA536363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S42746Medicare UPIN