Provider Demographics
NPI:1073596136
Name:WEATHERSTON, SEAN R (PT)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:R
Last Name:WEATHERSTON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2101 W GROUSE ST
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-8353
Mailing Address - Country:US
Mailing Address - Phone:208-465-8087
Mailing Address - Fax:208-454-0727
Practice Address - Street 1:211 E LOGAN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4835
Practice Address - Country:US
Practice Address - Phone:208-454-9839
Practice Address - Fax:208-454-0727
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1523225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1650156Medicare PIN