Provider Demographics
NPI:1245538669
Name:SULLIVAN, KEVIN JOHN (CRNA)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:JOHN
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 FARENHOLT AVE
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-3106
Mailing Address - Country:US
Mailing Address - Phone:671-787-8627
Mailing Address - Fax:
Practice Address - Street 1:280 PALE SAN VITORES RD
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3615
Practice Address - Country:US
Practice Address - Phone:671-647-4542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-09
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCRNA000407367500000X
FLARNP9237910367500000X
GUNP0152367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG00N4OtherBCBS ATTACHED TO GRP 77329
FLP01195017OtherRAILROAD MEDICARE
FL003321600Medicaid
FL003321600Medicaid