Healthcare Provider Details

I. General information

NPI: 1073022372
Provider Name (Legal Business Name): SEAN SULLIVAN DWYER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2017
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 W 65TH ST
EDINA MN
55435-1706
US

IV. Provider business mailing address

3500 AMERICAN BLVD W STE 300
BLOOMINGTON MN
55431-4442
US

V. Phone/Fax

Practice location:
  • Phone: 952-456-7000
  • Fax:
Mailing address:
  • Phone: 952-512-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12601
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: