Provider Demographics
NPI:1821634239
Name:SULLIVAN, JUSTIN MICHEAL (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MICHEAL
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E LAUREL RD
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1301
Mailing Address - Country:US
Mailing Address - Phone:844-542-2273
Mailing Address - Fax:
Practice Address - Street 1:205 E LAUREL RD
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1301
Practice Address - Country:US
Practice Address - Phone:856-344-2315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00553600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0714275Medicaid