Provider Demographics
NPI:1548249477
Name:SULLIVAN, JOHN L (PAC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 S STATE ST
Mailing Address - Street 2:FINANCE
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-3530
Mailing Address - Country:US
Mailing Address - Phone:302-674-4700
Mailing Address - Fax:302-735-3842
Practice Address - Street 1:540 S GOVERNORS AVE
Practice Address - Street 2:SUITE 101A
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-3530
Practice Address - Country:US
Practice Address - Phone:302-744-7980
Practice Address - Fax:302-744-7989
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC50000356363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE010768D18Medicare PIN
DE013981S72Medicare ID - Type Unspecified
P75206Medicare UPIN