Provider Demographics
NPI:1689122129
Name:DOUGLAS, SEAN T (PA-C)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:T
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:360 US HIGHWAY 1 BYP UNIT 102
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-7105
Mailing Address - Country:US
Mailing Address - Phone:603-410-6700
Mailing Address - Fax:603-319-8308
Practice Address - Street 1:999 DALTON AVE
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-2903
Practice Address - Country:US
Practice Address - Phone:413-242-6577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-13
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY019994-1363A00000X
MAPA5886363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant