Healthcare Provider Details

I. General information

NPI: 1689090722
Provider Name (Legal Business Name): MEAGAN A SULLIVAN-PRUYN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEAGAN A SULLIVAN PA-C

II. Dates (important events)

Enumeration Date: 03/13/2014
Last Update Date: 11/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 BROADWAY
SEATTLE WA
98122
US

IV. Provider business mailing address

PO BOX 25608
SALT LAKE CITY UT
84125-0608
US

V. Phone/Fax

Practice location:
  • Phone: 206-215-2520
  • Fax: 206-386-3180
Mailing address:
  • Phone: 206-320-4476
  • Fax: 206-568-7043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60435682
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: