Healthcare Provider Details

I. General information

NPI: 1235551953
Provider Name (Legal Business Name): JOHN L SULLIVAN PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2014
Last Update Date: 01/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6720 E GREEN LAKE WAY N
SEATTLE WA
98103-5439
US

IV. Provider business mailing address

6720 E GREEN LAKE WAY N
SEATTLE WA
98103-5439
US

V. Phone/Fax

Practice location:
  • Phone: 206-525-9666
  • Fax:
Mailing address:
  • Phone: 206-525-9666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberP3 60394421
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: