=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699102988
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHLEEN MARIE SULLIVAN PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2013
-----------------------------------------------------
Last Update Date | 02/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 GRANT RD
-----------------------------------------------------
City | MOUNTAIN VIEW
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94040-4302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-940-7055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2233 LARKIN ST APT 2
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94109-1960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-420-7792
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA23126
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------