Provider Demographics
NPI:1396796843
Name:SULLIVAN, DONNA J (PA-C)
Entity type:Individual
Prefix:MS
First Name:DONNA
Middle Name:J
Last Name:SULLIVAN
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 780
Mailing Address - Street 2:
Mailing Address - City:GRINNELL
Mailing Address - State:IA
Mailing Address - Zip Code:50112-0780
Mailing Address - Country:US
Mailing Address - Phone:641-236-2500
Mailing Address - Fax:641-236-2539
Practice Address - Street 1:210 4TH AVE
Practice Address - Street 2:
Practice Address - City:GRINNELL
Practice Address - State:IA
Practice Address - Zip Code:50112-1898
Practice Address - Country:US
Practice Address - Phone:641-236-2500
Practice Address - Fax:641-236-2539
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1028363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1028OtherLICENSE NUMBER
IA1028OtherLICENSE NUMBER
IAI15853Medicare ID - Type UnspecifiedMEDICARE NUMBER
IAI15627Medicare ID - Type UnspecifiedMEDICARE NUMBER
IAP02118Medicare UPIN