Active NPI
Kermit C Sullivan III, ATC
- Athletic Trainer
- Nampa, ID
National Provider Identifier
1124157185
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Athletic Trainer
- License
- AT-182
- Practice address
- 1303 E Greenhurst Rd
Nampa, ID 83686-7216 - Phone
- (208) 468-7820
- NPI assigned
- Mar 5, 2007
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Athletic Trainer | 2255A2300X | AT-182 | ID | Primary |
Addresses
Primary practice location
1303 E Greenhurst Rd
Nampa, ID 83686-7216
Mailing address
231 N Turtle Dove Way
Nampa, ID 83651-8363
Phone (208) 442-4354
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| AT-182 | ID | MD | Athletic Trainer |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1173052800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1124157185",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "231 N TURTLE DOVE WAY",
"city": "NAMPA",
"state": "ID",
"postal_code": "836518363",
"telephone_number": "208-442-4354"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1303 E GREENHURST RD",
"city": "NAMPA",
"state": "ID",
"postal_code": "836867216",
"telephone_number": "208-468-7820"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SULLIVAN",
"first_name": "KERMIT",
"middle_name": "C",
"name_prefix": "Mr.",
"name_suffix": "III",
"credential": "ATC",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-03-05",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "2255A2300X",
"taxonomy_group": "",
"desc": "Specialist/Technologist, Athletic Trainer",
"state": "ID",
"license": "AT-182",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Nampa, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.