Provider Demographics
NPI:1942778246
Name:SULLIVAN, SHEA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:SHEA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 E BROWN RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-5226
Mailing Address - Country:US
Mailing Address - Phone:480-649-9000
Mailing Address - Fax:480-248-9206
Practice Address - Street 1:9220 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020
Practice Address - Country:US
Practice Address - Phone:602-254-7077
Practice Address - Fax:602-254-7078
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7267207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine