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General NPI Number Information
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NPI Number | 1326198110
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Entity Type | Individual
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Provider Name | LEN SULLIVAN PA
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Gender | Male
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Dates
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Enumeration Date | 01/12/2007
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Last Update Date | 11/01/2023
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Provider Practice Location Address
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Address Line | 305 MALLARD LN
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City | TAYLOR
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State | TX
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Zip | 76574-1208
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Country | US
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Telephone | 512-352-7611
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Fax | 512-352-2196
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Provider Business Mailing Address
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Address Line | PO BOX 844658
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City | DALLAS
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State | TX
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Zip | 75284-4658
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Country | US
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Telephone | 254-724-2111
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 00703
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 902
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License Number State | MA
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA11712
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License Number State | TX
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