Provider Demographics
NPI:1225225485
Name:CRESAP, SEAN DOMINIC (CPO)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:DOMINIC
Last Name:CRESAP
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 N CHELAN AVE
Mailing Address - Street 2:A-5
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-6622
Mailing Address - Country:US
Mailing Address - Phone:509-663-2490
Mailing Address - Fax:509-663-2147
Practice Address - Street 1:630 N CHELAN AVE
Practice Address - Street 2:A-5
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-6622
Practice Address - Country:US
Practice Address - Phone:509-663-2490
Practice Address - Fax:509-663-2147
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPS000001621744P3200X
WA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8419053Medicaid