Provider Demographics
NPI:1619151610
Name:SULLIVAN, ANEESHA HANAN BAKIR (PA-C)
Entity type:Individual
Prefix:
First Name:ANEESHA
Middle Name:HANAN BAKIR
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANEESHA
Other - Middle Name:HANAN
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:9169 W VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-2942
Mailing Address - Country:US
Mailing Address - Phone:623-233-6676
Mailing Address - Fax:602-314-4579
Practice Address - Street 1:11034 N 23RD DR STE 105B
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-4743
Practice Address - Country:US
Practice Address - Phone:602-639-0189
Practice Address - Fax:844-955-2502
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5471496385HR2055X, 385HR2055X
AZ4842363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ669150Medicaid
AZZ150918Medicare PIN