Basic Information
| Provider Information | |||||||||
| NPI: | 1194781617 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | WENDY | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 CROSSROADS DR | ||||||||
| Address2: | SUITE 306 | ||||||||
| City: | OWINGS MILLS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211175421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4437382872 | ||||||||
| FaxNumber: | 4437382713 | ||||||||
| Practice Location | |||||||||
| Address1: | 6820 HOSPITAL DR | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212374352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103916131 | ||||||||
| FaxNumber: | 4103916144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2006 | ||||||||
| LastUpdateDate: | 11/01/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110 002181 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | C0002516 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 010234085 | 05 | VA | MEDICAID | 541203530 | 01 | VA | TAS IDENTIFICATION NUMBER | OTHER |