Provider Demographics
NPI:1184728875
Name:SULLIVAN, PAUL J (PA-C)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:200 LAKE RD
Mailing Address - Street 2:APT 201
Mailing Address - City:BELTON
Mailing Address - State:TX
Mailing Address - Zip Code:76513-1524
Mailing Address - Country:US
Mailing Address - Phone:724-953-1877
Mailing Address - Fax:
Practice Address - Street 1:36000 DARNALL LOOP, ROOM 1272
Practice Address - Street 2:CARL R. DARNALL ARMY MEDICAL CENTER
Practice Address - City:FT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-288-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003014L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S97452Medicare UPIN
093710FKCMedicare PIN