Provider Demographics
NPI:1336384783
Name:WEISER, SEAN MATHEW (LMT)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:MATHEW
Last Name:WEISER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1153 WILLOWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-5432
Mailing Address - Country:US
Mailing Address - Phone:850-384-1023
Mailing Address - Fax:
Practice Address - Street 1:744 E BURGESS RD
Practice Address - Street 2:SUITE A105
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-6227
Practice Address - Country:US
Practice Address - Phone:850-384-1023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-12
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA-32816174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC1521OtherBCBS