# MARK NICHOLAS SULLIVAN

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** No

## Provider details

- **NPI number:** 1679653455
- **Gender:** Man
- **Credential:** PT

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 225100000X | Physical Therapist | 5549024 | WI | Yes |

## Other

- **Enumeration date:** 10/16/2006
- **Last updated:** 07/08/2007

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 40475300 | — | WI |
| 01 | — | 5415000450861 | DPI | WI |