Provider Demographics
NPI:1629021142
Name:GUEVARA, SEAN P (MD)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:P
Last Name:GUEVARA
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 1:320 W 10TH AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-6302
Mailing Address - Country:US
Mailing Address - Phone:509-221-5910
Mailing Address - Fax:509-221-5912
Practice Address - Street 1:320 W 10TH AVE STE 102
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-6302
Practice Address - Country:US
Practice Address - Phone:509-221-5910
Practice Address - Fax:509-221-5912
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044613208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8430183Medicaid
WA8430183Medicaid
8854927Medicare ID - Type Unspecified