Provider Demographics
NPI:1457519829
Name:CUSHING, SEAN ROBERT (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:ROBERT
Last Name:CUSHING
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5806 NE 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97211-2710
Mailing Address - Country:US
Mailing Address - Phone:971-235-5913
Mailing Address - Fax:
Practice Address - Street 1:10123 SE MARKET ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2532
Practice Address - Country:US
Practice Address - Phone:503-251-6168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 19589363AM0700X
ORPA 153108363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU173ZMedicare PIN