Provider Demographics
NPI:1104051549
Name:SULLIVAN, JACQUELINE GLORIA (PA)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:GLORIA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:232 SPRINGMEADOW DR
Mailing Address - Street 2:UNIT C
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:718-920-4321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2009-05-28
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant