Individual
JENNA SULLIVAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MPAS, PA-C
Contact information
Practice address
327 CENTRAL AVENUE SE, MINNEAPOLIS, MN 55414
(612) 379-1119
Mailing address
327 CENTRAL AVENUE SE, MINNEAPOLIS, MN 55414
(612) 379-1119
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
10943
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10943
MN BOARD OF MEDICAL PRACTICE LICENSE
MN
01
—
1098277
NCCPA CERTIFICATE
MN
Enumeration date
07/14/2011
Last updated
06/20/2016
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