Healthcare Provider Details

I. General information

NPI: 1427051713
Provider Name (Legal Business Name): COLLEEN ANASTASIA O'SULLIVAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 12/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1253 NW CANAL BLVD
REDMOND OR
97708
US

IV. Provider business mailing address

PO BOX 6096
BEND OR
97708-6096
US

V. Phone/Fax

Practice location:
  • Phone: 541-548-8131
  • Fax: 541-460-4028
Mailing address:
  • Phone: 541-548-8131
  • Fax: 541-460-4028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA20422
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number169425
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: