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Individual
MARK T SULLIVAN
Active
Individual
MARK T SULLIVAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
205
MT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000900883
BLUECROSS BLUESHIELD
MT
05
—
119184500
—
WY
05
—
435438
—
MT
01
—
970010277
RR MEDICARE
MT
Enumeration date
08/19/2005
Last updated
04/29/2008
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