Provider Demographics
NPI:1962751545
Name:SULLIVAN, DAVID YUTAKA (FNP)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:YUTAKA
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AZ
Mailing Address - Zip Code:86047-2169
Mailing Address - Country:US
Mailing Address - Phone:928-289-6230
Mailing Address - Fax:928-289-6229
Practice Address - Street 1:500 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-2169
Practice Address - Country:US
Practice Address - Phone:928-289-6230
Practice Address - Fax:928-289-6229
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN174273163WP2201X
AZ224965363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care