Provider Demographics
NPI:1750683967
Name:SULLIVAN, HEATHER B (PA-C)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:B
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 1:2700 N CENTRAL AVE STE 1050
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1217
Mailing Address - Country:US
Mailing Address - Phone:602-376-3353
Mailing Address - Fax:
Practice Address - Street 1:1465 W CHANDLER BLVD BLDG A
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6237
Practice Address - Country:US
Practice Address - Phone:602-344-6600
Practice Address - Fax:602-344-6601
Is Sole Proprietor?:No
Enumeration Date:2010-11-19
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4756363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ572703Medicaid
AZ572703Medicaid
AZZ141820Medicare PIN