Provider Demographics
NPI:1336621473
Name:SULLIVAN-SPRINGHETTI, ROSE K (PA-C)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:K
Last Name:SULLIVAN-SPRINGHETTI
Suffix:
Gender:F
Credentials:PA-C
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 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:5350 TALLMAN AVE NW STE 520
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-5910
Practice Address - Country:US
Practice Address - Phone:206-215-4250
Practice Address - Fax:206-215-4252
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61023919363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2153785Medicaid
WA1336621473Medicaid