Provider Demographics
NPI:1427841287
Name:SULLIVAN, MARK (PTA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 LANDSDOWNE CIR
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-3912
Mailing Address - Country:US
Mailing Address - Phone:843-263-9277
Mailing Address - Fax:
Practice Address - Street 1:41 COBBLERS WAY
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28804-1463
Practice Address - Country:US
Practice Address - Phone:828-575-0201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-26
Last Update Date:2025-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA8418225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant