Provider Demographics
NPI:1811205750
Name:SULLIVAN, LISA RENEE (PA-C)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:RENEE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:44305 HARMONY LN
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-2449
Mailing Address - Country:US
Mailing Address - Phone:734-716-5588
Mailing Address - Fax:
Practice Address - Street 1:44305 HARMONY LN
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-2449
Practice Address - Country:US
Practice Address - Phone:734-716-5588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-14
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005958363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601005958OtherSTATE LICENSE