1073596136 NPI number — MR. SEAN R WEATHERSTON P.T.

Table of content: MR. SEAN R WEATHERSTON P.T. (NPI 1073596136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073596136 NPI number — MR. SEAN R WEATHERSTON P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEATHERSTON
Provider First Name:
SEAN
Provider Middle Name:
R
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073596136
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/04/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 W GROUSE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAMPA
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83651-8353
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-465-8087
Provider Business Mailing Address Fax Number:
208-454-0727

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
211 E LOGAN ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
CALDWELL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83605-4835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-454-9839
Provider Business Practice Location Address Fax Number:
208-454-0727
Provider Enumeration Date:
11/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1523 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com