Provider Demographics
NPI:1467034090
Name:SULLIVAN, ANNA NICOLE POWELL (PA-C)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:NICOLE POWELL
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:NICOLE
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:129 LEACROFT WAY
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-6703
Mailing Address - Country:US
Mailing Address - Phone:919-656-5170
Mailing Address - Fax:
Practice Address - Street 1:310 COMAL ST STE 200
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78702-4599
Practice Address - Country:US
Practice Address - Phone:737-270-9500
Practice Address - Fax:833-906-2436
Is Sole Proprietor?:No
Enumeration Date:2021-04-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-11205363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant