MEDICARE: SCOTT G 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	363AM0700X	Medical Physician Assistant	PA9110596	FL

General Provider Information

NPI Number	:	1750440004
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SCOTT G SULLIVAN PA

Provider Business Mailing Address
First Line	:	408 W 19TH ST
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4602
Country	:	US
Telephone Number	:	850-481-1101
Fax Number	:

Provider Business Practice Location Address
First Line	:	408 W 19TH ST
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4602
Country	:	US
Telephone Number	:	850-481-1101
Fax Number	:

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

Provider Enumeration Date	:	12/06/2006
Last Update Date	:	07/15/2023

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Directions to “ SCOTT G SULLIVAN PA” Practice Location

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