Provider Demographics
NPI:1073078432
Name:MCMULLEN, SEAN THOMAS
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:THOMAS
Last Name:MCMULLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2904 PETTY JAY RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-2862
Mailing Address - Country:US
Mailing Address - Phone:502-718-7260
Mailing Address - Fax:
Practice Address - Street 1:2904 PETTY JAY RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-2862
Practice Address - Country:US
Practice Address - Phone:502-718-7260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-09
Last Update Date:2019-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer