Healthcare Provider Details

I. General information

NPI: 1023624194
Provider Name (Legal Business Name): ANNE MARIE SULLIVAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2020
Last Update Date: 10/12/2020
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1528 WALNUT ST STE 950
PHILADELPHIA PA
19102-3628
US

IV. Provider business mailing address

1500 LOCUST ST APT 3406
PHILADELPHIA PA
19102-4323
US

V. Phone/Fax

Practice location:
  • Phone: 267-273-1196
  • Fax: 267-273-1193
Mailing address:
  • Phone: 717-404-9328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA061897
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: