Healthcare Provider Details

I. General information

NPI: 1619151610
Provider Name (Legal Business Name): ANEESHA HANAN BAKIR SULLIVAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANEESHA HANAN COLE PHYSICIAN ASSISTANT

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11034 N 23RD DR STE 105B
PHOENIX AZ
85029-4743
US

IV. Provider business mailing address

9169 W VAN BUREN ST
TOLLESON AZ
85353-2942
US

V. Phone/Fax

Practice location:
  • Phone: 602-639-0189
  • Fax: 844-955-2502
Mailing address:
  • Phone: 623-233-6676
  • Fax: 602-314-4579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4842
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number5471496
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: