Provider Demographics
NPI:1780067678
Name:SULLIVAN, ANDREW (PA-C)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
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 1:302 NE 14TH ST
Mailing Address - Street 2:
Mailing Address - City:LEON
Mailing Address - State:IA
Mailing Address - Zip Code:50144-1206
Mailing Address - Country:US
Mailing Address - Phone:641-446-2383
Mailing Address - Fax:
Practice Address - Street 1:802 ACKERLY ST
Practice Address - Street 2:
Practice Address - City:LAMONI
Practice Address - State:IA
Practice Address - Zip Code:50140-1544
Practice Address - Country:US
Practice Address - Phone:641-784-7911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1127604363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant