Basic Information
| Provider Information | |||||||||
| NPI: | 1760917207 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | ASHLEY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROSA | ||||||||
| OtherFirstName: | TYLER | ||||||||
| OtherMiddleName: | ASHLEY | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1119 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029011119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014434150 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 KETTLE POINT AVE | ||||||||
| Address2: | |||||||||
| City: | EAST PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029145375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014539032 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2017 | ||||||||
| LastUpdateDate: | 10/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00970 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.