Provider Demographics
NPI:1639659733
Name:SULLIVAN, KACEY (PA-C)
Entity type:Individual
Prefix:
First Name:KACEY
Middle Name:
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 1:910 W 5TH AVE STE 900
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2948
Mailing Address - Country:US
Mailing Address - Phone:509-755-5500
Mailing Address - Fax:509-744-1741
Practice Address - Street 1:910 W 5TH AVE STE 900
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2948
Practice Address - Country:US
Practice Address - Phone:509-755-5500
Practice Address - Fax:509-744-1741
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61190646363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical