Basic Information
| Provider Information | |||||||||
| NPI: | 1336325067 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | KEZIA | ||||||||
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| Credential: | RPA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2 | ||||||||
| Address2: | |||||||||
| City: | POPLAR RIDGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 131390002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152095244 | ||||||||
| FaxNumber: | 3153645391 | ||||||||
| Practice Location | |||||||||
| Address1: | 17 LANSING ST | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130211983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3155670437 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2008 | ||||||||
| LastUpdateDate: | 03/04/2019 | ||||||||
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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 | 011828 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 03278613 | 05 | NY | MEDICAID |