Provider Demographics
NPI:1124455704
Name:SULLIVAN, LAURA NASTASSJA (PA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:NASTASSJA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751274
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1274
Mailing Address - Country:US
Mailing Address - Phone:919-620-4700
Mailing Address - Fax:
Practice Address - Street 1:1011 PEMBERTON HILL RD
Practice Address - Street 2:STE 101
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-4266
Practice Address - Country:US
Practice Address - Phone:919-620-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-27
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04483363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant