Provider Demographics
NPI:1851766026
Name:PAUL, LAURA SULLIVAN (PA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:SULLIVAN
Last Name:PAUL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:JEAN
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:SUITE M-273
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:248-804-2448
Mailing Address - Fax:
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:SUITE M-273
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:248-804-2448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-14
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007525363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant