Provider Demographics
NPI:1720262421
Name:WHITE, SEAN RAE (MD)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:RAE
Last Name:WHITE
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 1:501 W PIONEER AVE
Mailing Address - Street 2:
Mailing Address - City:MONTESANO
Mailing Address - State:WA
Mailing Address - Zip Code:98563-4323
Mailing Address - Country:US
Mailing Address - Phone:360-637-8108
Mailing Address - Fax:360-637-8709
Practice Address - Street 1:501 W PIONEER AVE
Practice Address - Street 2:
Practice Address - City:MONTESANO
Practice Address - State:WA
Practice Address - Zip Code:98563-4323
Practice Address - Country:US
Practice Address - Phone:360-637-8108
Practice Address - Fax:360-637-8709
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-18
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ81719208000000X
WAMD60082203208000000X
WA60082203208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1689027328OtherGROUP NPI
WA1912130006OtherGROUP NPI
AZ81719OtherTRAINING PERMIT