Provider Demographics
NPI:1932556685
Name:SULLIVAN, PATRICK
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7211 BEACON WOODS DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-1975
Mailing Address - Country:US
Mailing Address - Phone:727-967-8657
Mailing Address - Fax:727-857-5928
Practice Address - Street 1:7211 BEACON WOODS DR
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-1975
Practice Address - Country:US
Practice Address - Phone:727-967-8657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10115261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center