Basic Information
| Provider Information | |||||||||
| NPI: | 1225075328 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 BORTHWICK AVE | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038017128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035594111 | ||||||||
| FaxNumber: | 6035594110 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MCGREGOR ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031023730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036636340 | ||||||||
| FaxNumber: | 6036636822 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 01/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA 880 | ME | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 0238P | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 3076816 | 05 | NH | MEDICAID |