Provider Demographics
NPI:1194781617
Name:SULLIVAN, WENDY S (PA)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:S
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:25 CROSSROADS DR
Mailing Address - Street 2:SUITE 306
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5421
Mailing Address - Country:US
Mailing Address - Phone:443-738-2872
Mailing Address - Fax:443-738-2713
Practice Address - Street 1:6820 HOSPITAL DR
Practice Address - Street 2:SUITE 210
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-4352
Practice Address - Country:US
Practice Address - Phone:410-391-6131
Practice Address - Fax:410-391-6144
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2012-11-01
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Provider Licenses
StateLicense IDTaxonomies
VA0110 002181363A00000X
MDC0002516363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010234085Medicaid
VA541203530OtherTAS IDENTIFICATION NUMBER