Justin J Sullivan, PT

Primary specialty

SpecialistTaxonomy code 174400000X

License

P13748 Issued in NC

Practice address

123 Capcom Ave Ste 2
Wake Forest, NC 27587-6517

Phone

(919) 551-4142

Fax

(919) 694-6417

NPI assigned

Jul 11, 2012

Last updated

Mar 3, 2021By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1341964800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1614729600000",
    "number": "1548525090",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1333 LITCHBOROUGH WAY",
            "city": "WAKE FOREST",
            "state": "NC",
            "postal_code": "275873612",
            "telephone_number": "191-955-1414",
            "fax_number": "919-694-9417"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "123 CAPCOM AVE STE 2",
            "city": "WAKE FOREST",
            "state": "NC",
            "postal_code": "275876517",
            "telephone_number": "919-551-4142",
            "fax_number": "919-694-6417"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "843 Wake Forest Business Park",
            "address_2": "Suite 110",
            "address_purpose": "LOCATION",
            "city": "Wake Forest",
            "state": "NC",
            "postal_code": "275876577",
            "country_code": "US",
            "telephone_number": "919-570-7080",
            "fax_number": "919-570-7071",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "SULLIVAN",
        "first_name": "JUSTIN",
        "middle_name": "J",
        "credential": "PT",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2012-07-11",
        "last_updated": "2021-03-03",
        "certification_date": "2021-03-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "",
            "desc": "Specialist",
            "state": "NC",
            "license": "P13748",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Specialist in Wake Forest, NC
• Providers in Wake Forest, NC by specialty
• Specialist in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 3, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.