Provider Demographics
NPI:1447606231
Name:PRENDERGAST, SEAN JOSEPH
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:JOSEPH
Last Name:PRENDERGAST
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:PO BOX 1193
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1193
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:525 N SANTIAM HWY
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-4363
Practice Address - Country:US
Practice Address - Phone:541-258-2101
Practice Address - Fax:541-451-7862
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD193346207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine