Provider Demographics
NPI:1174501191
Name:FAHERTY, SEAN (MD)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:FAHERTY
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 1:2300 E 30TH ST
Mailing Address - Street 2:STE C2
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8991
Mailing Address - Country:US
Mailing Address - Phone:505-324-1000
Mailing Address - Fax:505-324-1199
Practice Address - Street 1:2300 E 30TH ST
Practice Address - Street 2:BLDG B, STE 102
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8990
Practice Address - Country:US
Practice Address - Phone:505-324-1000
Practice Address - Fax:505-324-1199
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM98-47207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJQ3766Medicaid
NM32756OtherPRESBYTERIAN SALUD
NM12988OtherLOEVLACE
NM201013243OtherPRESBYTERIAN HEALTH PLAN
080153393OtherRAILROAD RETIREMENT
NMNM004194OtherBLUE CROSS
NM12988OtherLOEVLACE
850462631OtherEIN