Provider Demographics
NPI:1023128451
Name:SULLIVAN, PAUL B (CRNA)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:B
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:21980 E COUNTRY VISTA DR
Mailing Address - Street 2:STE 200
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-6025
Mailing Address - Country:US
Mailing Address - Phone:509-926-1770
Mailing Address - Fax:509-228-9542
Practice Address - Street 1:1200 W FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:COLFAX
Practice Address - State:WA
Practice Address - Zip Code:99111-9552
Practice Address - Country:US
Practice Address - Phone:509-926-1770
Practice Address - Fax:509-228-9542
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAAP30005473367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9617499Medicaid
WA912153623OtherTAX ID
WAAB25659Medicare ID - Type Unspecified