Provider Demographics
NPI:1104408285
Name:SULLIVAN, RONIN ANTHONY
Entity type:Individual
Prefix:MR
First Name:RONIN
Middle Name:ANTHONY
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17858 E 54TH AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80249-8819
Mailing Address - Country:US
Mailing Address - Phone:850-543-7434
Mailing Address - Fax:
Practice Address - Street 1:17858 E 54TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80249-8819
Practice Address - Country:US
Practice Address - Phone:850-543-7434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program