Healthcare Provider Details

I. General information

NPI: 1821098104
Provider Name (Legal Business Name): MICHAEL J. SULLIVAN M.S., P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 09/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 S JONES BLVD
LAS VEGAS NV
89107-2614
US

IV. Provider business mailing address

112 S JONES BLVD
LAS VEGAS NV
89107-2614
US

V. Phone/Fax

Practice location:
  • Phone: 702-838-7110
  • Fax: 702-838-7112
Mailing address:
  • Phone: 702-838-7110
  • Fax: 702-838-7112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA536
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: