Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 04-33297 | KS |
N | 207QA0401X | Family Doctor - Addiction Medicine | 2014012167 | MO |
N | 208D00000X | General Practice Physician | 04-33297 | KS |
NPI | 1740300094 |
---|---|
Provider Name | Dr. Garrett Gray Sullivan |
First Address | Westwood, KS 66205-1747 |
Second Address | Westwood, KS 66205-1747 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/03/2007 |
Last Update Date | 04/03/2016 |