Provider Demographics
NPI:1427051713
Name:O'SULLIVAN, COLLEEN ANASTASIA (PA)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ANASTASIA
Last Name:O'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 6096
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-6096
Mailing Address - Country:US
Mailing Address - Phone:541-548-8131
Mailing Address - Fax:541-460-4028
Practice Address - Street 1:1253 NW CANAL BLVD
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97708
Practice Address - Country:US
Practice Address - Phone:541-548-8131
Practice Address - Fax:541-460-4028
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20422363A00000X
OR169425363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP98954Medicare UPIN