1407056708 NPI number — JOHN THOMAS SULLIVAN PA-C

Table of content: JOHN THOMAS SULLIVAN PA-C (NPI 1407056708)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407056708 NPI number — JOHN THOMAS SULLIVAN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
JOHN
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407056708
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4811 E GRANT RD STE 261
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85712-2776
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-618-1010
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
522 W NEWTON ST STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15601-2890
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-838-7500
Provider Business Practice Location Address Fax Number:
724-837-6670
Provider Enumeration Date:
07/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  6307 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 113349 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com