Provider Demographics
NPI:1073617411
Name:MCKENNA, SEAN O (MD)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:O
Last Name:MCKENNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 980646
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298-5075
Mailing Address - Country:US
Mailing Address - Phone:804-828-0099
Mailing Address - Fax:804-828-6301
Practice Address - Street 1:1001 E MARSHALL ST
Practice Address - Street 2:PEDIATRICS
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5075
Practice Address - Country:US
Practice Address - Phone:804-828-0099
Practice Address - Fax:804-828-6301
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101234938208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010006848Medicaid
H90458Medicare UPIN
02236M93Medicare ID - Type Unspecified