Provider Demographics
NPI:1194076620
Name:SULLIVAN, KRISTIN MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:MARIE
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 1:125 PARKER HILL AVE
Mailing Address - Street 2:CONVERSE 4
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02120-2847
Mailing Address - Country:US
Mailing Address - Phone:617-754-6025
Mailing Address - Fax:617-754-6026
Practice Address - Street 1:125 PARKER HILL AVE
Practice Address - Street 2:CONVERSE 4
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02120-2847
Practice Address - Country:US
Practice Address - Phone:617-754-6025
Practice Address - Fax:617-754-6026
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4454363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant