Provider Demographics
NPI:1255526810
Name:SULLIVAN, MAURA K (PA)
Entity type:Individual
Prefix:
First Name:MAURA
Middle Name:K
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:1535 GULL ROAD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1630
Mailing Address - Country:US
Mailing Address - Phone:269-385-9900
Mailing Address - Fax:269-385-2140
Practice Address - Street 1:1535 GULL ROAD
Practice Address - Street 2:SUITE 105
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1630
Practice Address - Country:US
Practice Address - Phone:269-385-9900
Practice Address - Fax:269-385-2140
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2020-05-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601005124363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical