Provider Demographics
NPI:1750787123
Name:SULLIVAN, EMILY R (PA-C)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:R
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 1:100 WILSON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-7885
Mailing Address - Country:US
Mailing Address - Phone:831-242-8394
Mailing Address - Fax:
Practice Address - Street 1:1033 LOS PALOS DR STE A
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93901-3916
Practice Address - Country:US
Practice Address - Phone:831-757-2058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-13
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56405363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9108280OtherSTATE LICENSE