Healthcare Provider Details

I. General information

NPI: 1821634239
Provider Name (Legal Business Name): JUSTIN MICHEAL SULLIVAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2019
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E LAUREL RD
STRATFORD NJ
08084-1301
US

IV. Provider business mailing address

205 E LAUREL RD
STRATFORD NJ
08084-1301
US

V. Phone/Fax

Practice location:
  • Phone: 856-344-2315
  • Fax:
Mailing address:
  • Phone: 844-542-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00553600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: