Provider Demographics
NPI:1902929912
Name:SULLIVAN, PATRICIA (NP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:9279 LOCUST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:CA
Practice Address - Zip Code:95669
Practice Address - Country:US
Practice Address - Phone:209-245-6968
Practice Address - Fax:209-245-5135
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10070363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPO8192Medicare UPIN