Provider Demographics
NPI:1861455222
Name:SULLIVAN, PATRICIA SUSANA (MD MPH)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:SUSANA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14251 N 6TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-4224
Mailing Address - Country:US
Mailing Address - Phone:602-882-9486
Mailing Address - Fax:480-269-9462
Practice Address - Street 1:702 E BELL RD
Practice Address - Street 2:STE 112
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-6639
Practice Address - Country:US
Practice Address - Phone:602-826-7134
Practice Address - Fax:480-269-9462
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15987208D00000X
AZ40062207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ358212Medicaid
SC159875Medicaid
SC2015987OtherCDS
F427208066OtherMEDICARE ID-TYPE UNSELECTED
F427208066OtherMEDICARE ID-TYPE UNSELECTED
AZ358212Medicaid
1861455222Medicare NSC
SC159875Medicaid