Provider Demographics
NPI:1750440004
Name:SULLIVAN, SCOTT G (PA)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:G
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 1:408 W 19TH ST
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4602
Mailing Address - Country:US
Mailing Address - Phone:850-481-1101
Mailing Address - Fax:
Practice Address - Street 1:408 W 19TH ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4602
Practice Address - Country:US
Practice Address - Phone:850-481-1101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2023-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110596363AM0700X
ALPA570363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical