Provider Demographics
NPI:1528027653
Name:MADSEN, SEAN COURTNEY (INDEPENDANT DUTY COR)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:COURTNEY
Last Name:MADSEN
Suffix:
Gender:M
Credentials:INDEPENDANT DUTY COR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1092 HOMOJA DR APT B
Mailing Address - Street 2:
Mailing Address - City:PORT HUENEME
Mailing Address - State:CA
Mailing Address - Zip Code:93041-3953
Mailing Address - Country:US
Mailing Address - Phone:805-603-9816
Mailing Address - Fax:
Practice Address - Street 1:NMCB 3
Practice Address - Street 2:UNIT 25269
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96601-4921
Practice Address - Country:US
Practice Address - Phone:805-982-6131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman