Provider Demographics
NPI:1700884913
Name:SULLIVAN, MATTHEW DALEY (PA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:DALEY
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 1:830 OAK ST
Mailing Address - Street 2:125E
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1168
Mailing Address - Country:US
Mailing Address - Phone:508-588-1505
Mailing Address - Fax:508-588-1508
Practice Address - Street 1:830 OAK ST
Practice Address - Street 2:125E
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1168
Practice Address - Country:US
Practice Address - Phone:508-588-1505
Practice Address - Fax:508-588-1508
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1141363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AP1310Medicare ID - Type Unspecified
P12146Medicare UPIN