Provider Demographics
NPI:1841212032
Name:SULLIVAN, THOMAS BRIAN (PAC)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:BRIAN
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4133 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BROAD TOP
Mailing Address - State:PA
Mailing Address - Zip Code:16621-9001
Mailing Address - Country:US
Mailing Address - Phone:814-635-2916
Mailing Address - Fax:814-635-2918
Practice Address - Street 1:790 BRYAN ST
Practice Address - Street 2:
Practice Address - City:HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:16652-2410
Practice Address - Country:US
Practice Address - Phone:814-643-8299
Practice Address - Fax:814-643-8300
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0A002066363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
376731WFPOtherMEDICARE
PA103205926Medicaid