Individual
THAXTON SULLIVAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
572 ESSAYONS DR., 92ND ENGINEER BN, HINESVILLE, GA 31313-3131
(601) 422-7472
Mailing address
3 COURTLAND DR APT 50, HATTIESBURG, MS 39402-8186
(601) 422-7472
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
AT9120
TX
2255A2300X
Athletic Trainer
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Other
Enumeration date
09/24/2020
Last updated
03/22/2023
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