Provider Demographics
NPI:1205187283
Name:SULLIVAN, VICTORIA MARY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:MARY
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 LACEY RD
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:CT
Mailing Address - Zip Code:06524-3021
Mailing Address - Country:US
Mailing Address - Phone:203-520-4210
Mailing Address - Fax:
Practice Address - Street 1:55 LOCK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-3603
Practice Address - Country:US
Practice Address - Phone:203-432-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-01
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016001363A00000X
CT3031363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant