Provider Demographics
NPI:1154930931
Name:SULLIVAN, JOSHUA TIMOTHY
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:TIMOTHY
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 1:2415 RIDGECROFT AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8010
Mailing Address - Country:US
Mailing Address - Phone:616-560-6453
Mailing Address - Fax:
Practice Address - Street 1:43 NEW SCOTLAND AVE # MC-139
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3478
Practice Address - Country:US
Practice Address - Phone:518-262-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic