Healthcare Provider Details

I. General information

NPI: 1700023348
Provider Name (Legal Business Name): MARK MONTOGOMERY SULLIVAN PAC, MPAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2009
Last Update Date: 01/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5121 COTTONWOOD ST SUITE 320
MURRAY UT
84107-5701
US

IV. Provider business mailing address

2609 OAK CREEK DR
SANDY UT
84093-6522
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-3380
  • Fax:
Mailing address:
  • Phone: 801-244-2834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7131889-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: