Provider Demographics
NPI:1871647099
Name:SULLIVAN, P. ALEXANDER (LMT 2569)
Entity Type:Individual
Prefix:MR
First Name:P.
Middle Name:ALEXANDER
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LMT 2569
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 LUISA ST STE 9
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4175
Mailing Address - Country:US
Mailing Address - Phone:505-501-4263
Mailing Address - Fax:505-501-4263
Practice Address - Street 1:1210 LUISA ST STE 9
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4175
Practice Address - Country:US
Practice Address - Phone:505-501-4263
Practice Address - Fax:505-501-4263
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM#2569225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist