1003426230 NPI number — SEAN DEANE LEJONVARN CNP

Table of content: SEAN DEANE LEJONVARN CNP (NPI 1003426230)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003426230 NPI number — SEAN DEANE LEJONVARN CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEJONVARN
Provider First Name:
SEAN
Provider Middle Name:
DEANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNP
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:
1003426230
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1936 MERIDIAN CURV
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARVER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55315-4418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-232-1209
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
212 W LAKE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WACONIA
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55387-1014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-232-1209
Provider Business Practice Location Address Fax Number:
833-630-0621
Provider Enumeration Date:
08/03/2020

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: 363LF0000X , with the licence number:  7663 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: - , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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