MEDICARE: TESSA SULLIVAN

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

General Provider Information

NPI Number	:	1508672213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TESSA SULLIVAN

Provider Business Mailing Address
First Line	:	4566 E INVERNESS AVE STE 208
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85206-4634
Country	:	US
Telephone Number	:	480-993-1300
Fax Number	:

Provider Business Practice Location Address
First Line	:	4566 E INVERNESS AVE STE 208
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85206-4634
Country	:	US
Telephone Number	:	480-993-1300
Fax Number	:

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

Provider Enumeration Date	:	12/06/2024
Last Update Date	:	12/02/2025

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Directions to “ TESSA SULLIVAN ” Practice Location

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