Provider Demographics
NPI:1487107728
Name:SULLIVAN, PATRICK (PT, DPT)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:WILFORD HALL AMBULATORY SURGICAL CENTER
Mailing Address - Street 2:1100 WILFORD HALL LOOP
Mailing Address - City:JBSA LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236-9908
Mailing Address - Country:US
Mailing Address - Phone:210-292-5040
Mailing Address - Fax:
Practice Address - Street 1:WILFORD HALL AMBULATORY SURGICAL CENTER
Practice Address - Street 2:1100 WILFORD HALL LOOP
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-9908
Practice Address - Country:US
Practice Address - Phone:210-292-5040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13121182251X0800X
CA2917042251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic