Provider Demographics
NPI:1942209333
Name:SULLIVAN, EDWARD M (PA)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3209 WILLOW BND
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-3836
Mailing Address - Country:US
Mailing Address - Phone:972-686-8200
Mailing Address - Fax:972-686-7711
Practice Address - Street 1:341 WHEATFIELD DR
Practice Address - Street 2:SUITE 190
Practice Address - City:SUNNYVALE
Practice Address - State:TX
Practice Address - Zip Code:75182-4638
Practice Address - Country:US
Practice Address - Phone:972-686-8200
Practice Address - Fax:972-686-7711
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01111363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1013069541Medicaid
TX80N274Medicare ID - Type Unspecified
TXR59694Medicare UPIN