Provider Demographics
NPI:1164829057
Name:ANDERSON, SEAN (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 RENAISSANCE BLVD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3086
Mailing Address - Country:US
Mailing Address - Phone:405-844-4978
Mailing Address - Fax:405-844-0562
Practice Address - Street 1:605 S ORCHARD ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4218
Practice Address - Country:US
Practice Address - Phone:405-780-6650
Practice Address - Fax:405-844-0562
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN19170363LA2200X, 363LG0600X
TN19170363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology