Provider Demographics
NPI:1023624194
Name:SULLIVAN, ANNE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:ANNE MARIE
Middle Name:
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 1:1500 LOCUST ST APT 3406
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-4323
Mailing Address - Country:US
Mailing Address - Phone:717-404-9328
Mailing Address - Fax:
Practice Address - Street 1:1528 WALNUT ST STE 950
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3628
Practice Address - Country:US
Practice Address - Phone:267-273-1196
Practice Address - Fax:267-273-1193
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061897363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical