Basic Information
| Provider Information | |||||||||
| NPI: | 1396406039 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLY | ||||||||
| FirstName: | ELINE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 153 BIRCH BROOK RD | ||||||||
| Address2: | |||||||||
| City: | BRONXVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 107082021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6467314221 | ||||||||
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| Practice Location | |||||||||
| Address1: | 55 PALMER AVE | ||||||||
| Address2: | |||||||||
| City: | BRONXVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 107083403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9147875000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2022 | ||||||||
| LastUpdateDate: | 01/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.