Provider Demographics
NPI:1699102988
Name:SULLIVAN, KATHLEEN MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:SULLIVAN
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 1:2233 LARKIN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-1960
Mailing Address - Country:US
Mailing Address - Phone:415-420-7792
Mailing Address - Fax:
Practice Address - Street 1:2500 GRANT RD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-4302
Practice Address - Country:US
Practice Address - Phone:650-940-7055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-01
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA23126363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant