Provider Demographics
NPI:1740624691
Name:STEVENS, SEAN M (DO)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:M
Last Name:STEVENS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N RAINBOW BLVD
Mailing Address - Street 2:STE. 203
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-1082
Mailing Address - Country:US
Mailing Address - Phone:208-867-2102
Mailing Address - Fax:
Practice Address - Street 1:500 N RAINBOW BLVD
Practice Address - Street 2:STE. 203
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-1082
Practice Address - Country:US
Practice Address - Phone:208-867-2102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-23
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY283605207P00000X
NVDO2113207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program