MEDICARE: SYDNEY SULLIVAN PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant
2	363AM0700X	Medical Physician Assistant	PA.0007666	CO

General Provider Information

NPI Number	:	1184341422
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SYDNEY SULLIVAN PA

Provider Business Mailing Address
First Line	:	PO BOX 110429
Second Line	:
City	:	AURORA
State	:	CO
Zip	:	80042-0429
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1644 S GARFIELD ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80210-3006
Country	:	US
Telephone Number	:	303-524-2744
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2022
Last Update Date	:	01/30/2023

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Directions to “ SYDNEY SULLIVAN PA” Practice Location

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