Provider Demographics
NPI:1437994340
Name:SULLIVAN, MADISYN (PA-C)
Entity type:Individual
Prefix:
First Name:MADISYN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MADISYN
Other - Middle Name:
Other - Last Name:GOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:105 DAWSON LN
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-4594
Mailing Address - Country:US
Mailing Address - Phone:440-240-3645
Mailing Address - Fax:
Practice Address - Street 1:39 WINDY HILL RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:AL
Practice Address - Zip Code:36305
Practice Address - Country:US
Practice Address - Phone:334-793-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.2405363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant