Basic Information
| Provider Information | |||||||||
| NPI: | 1245870229 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | MEGAN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 CHURCH AVE | ||||||||
| Address2: | |||||||||
| City: | ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117513902 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1231 DEER PARK AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH BABYLON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117033104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316670388 | ||||||||
| FaxNumber: | 6319687705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2020 | ||||||||
| LastUpdateDate: | 02/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.