1144429820 NPI number — COSMETIC DERMATOLOGY BY SEAN DEGNAN

Table of content: (NPI 1144429820)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144429820 NPI number — COSMETIC DERMATOLOGY BY SEAN DEGNAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COSMETIC DERMATOLOGY BY SEAN DEGNAN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1144429820
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5757
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STATELINE
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89449-5757
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-588-3300
Provider Business Mailing Address Fax Number:
775-588-3353

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
165 HWY 50
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
STATELINE
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89449-5757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-588-3300
Provider Business Practice Location Address Fax Number:
775-588-3353
Provider Enumeration Date:
07/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ESTRADA
Authorized Official First Name:
MARY
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
775-588-3300

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  5488 , registered in the state of NV ; 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