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NPI Code Detail

MEDICARE: MR. MICHAEL J. SULLIVAN M.S., P.A.-C

MEDICARE: MR. MICHAEL J. SULLIVAN M.S., P.A.-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
1363AM0700XMedical Physician AssistantPA536NV

General Provider Information

NPI Number : 1821098104
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. MICHAEL J. SULLIVAN M.S., P.A.-C
Provider Business Mailing Address
First Line : 112 S JONES BLVD
Second Line :
City : LAS VEGAS
State : NV
Zip : 89107-2614
Country : US
Telephone Number : 702-838-7110
Fax Number : 702-838-7112
Provider Business Practice Location Address
First Line : 112 S JONES BLVD
Second Line :
City : LAS VEGAS
State : NV
Zip : 89107-2614
Country : US
Telephone Number : 702-838-7110
Fax Number : 702-838-7112
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/28/2005
Last Update Date : 09/30/2010

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