Provider Demographics
NPI:1346910171
Name:BOSSEN, SEAN LEE
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:LEE
Last Name:BOSSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 GLEN CREEK RD NW APT 60
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-3068
Mailing Address - Country:US
Mailing Address - Phone:971-283-5490
Mailing Address - Fax:
Practice Address - Street 1:2045 SILVERTON RD NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-0100
Practice Address - Country:US
Practice Address - Phone:503-364-3047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21-CRM-434175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist