Healthcare Provider Details

I. General information

NPI: 1811976079
Provider Name (Legal Business Name): CHESTER STEVEN SULLIVAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR
FT CARSON CO
80913-4603
US

IV. Provider business mailing address

3340 OAK CREEK DR E
COLORADO SPRINGS CO
80906-4514
US

V. Phone/Fax

Practice location:
  • Phone: 719-524-4068
  • Fax:
Mailing address:
  • Phone: 719-540-5753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: