Provider Demographics
NPI:1356886998
Name:SULLIVAN, KEVIN DOERR (PA)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:DOERR
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 CEDAR CREEK TER
Mailing Address - Street 2:
Mailing Address - City:IONE
Mailing Address - State:WA
Mailing Address - Zip Code:99139-5011
Mailing Address - Country:US
Mailing Address - Phone:509-442-3514
Mailing Address - Fax:
Practice Address - Street 1:208 CEDAR CREEK TER
Practice Address - Street 2:
Practice Address - City:IONE
Practice Address - State:WA
Practice Address - Zip Code:99139-5011
Practice Address - Country:US
Practice Address - Phone:509-442-3514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WATA60724212363A00000X
WAPA60716898363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant