MEDICARE: MRS. LAUREN TERESA SULLIVAN PA-C

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	PA06476	TX
2	363AM0700X	Medical Physician Assistant	PA06476	TX

General Provider Information

NPI Number	:	1346576535
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAUREN TERESA SULLIVAN PA-C

Provider Business Mailing Address
First Line	:	526 AMALFI DR
Second Line	:
City	:	KEMAH
State	:	TX
Zip	:	77565-1656
Country	:	US
Telephone Number	:	281-910-0367
Fax Number	:

Provider Business Practice Location Address
First Line	:	18123 UPPER BAY RD STE 200
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77058-3875
Country	:	US
Telephone Number	:	713-363-9090
Fax Number	:

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

Provider Enumeration Date	:	10/23/2009
Last Update Date	:	12/13/2023

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