Provider Demographics
NPI:1215075841
Name:SULLIVAN-MACIAS, TERRI ANN (PA-C)
Entity type:Individual
Prefix:MS
First Name:TERRI
Middle Name:ANN
Last Name:SULLIVAN-MACIAS
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 1:9888 RAVARI DR
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-3553
Mailing Address - Country:US
Mailing Address - Phone:714-827-1327
Mailing Address - Fax:
Practice Address - Street 1:1723 W BALL RD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-5502
Practice Address - Country:US
Practice Address - Phone:714-635-0363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11279363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical