Provider Demographics
NPI:1003967407
Name:SULLIVAN, SANDRA JEAN (PA)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:JEAN
Last Name:SULLIVAN
Suffix:
Gender:F
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:PO BOX 334
Mailing Address - Street 2:
Mailing Address - City:NEWRY
Mailing Address - State:ME
Mailing Address - Zip Code:04261-0334
Mailing Address - Country:US
Mailing Address - Phone:978-204-4533
Mailing Address - Fax:
Practice Address - Street 1:1976 WHITE MOUNTAIN HWY STE 105
Practice Address - Street 2:
Practice Address - City:NORTH CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03860-5147
Practice Address - Country:US
Practice Address - Phone:603-356-4940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2025-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3056363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS39734Medicare UPIN
MAAP0355Medicare PIN