Provider Demographics
NPI:1740817535
Name:KIESEL, SEAN ALTON (DO)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:ALTON
Last Name:KIESEL
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 1:1301 BERTHA HOWE AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:NV
Mailing Address - Zip Code:89027-7503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 BERTHA HOWE AVE STE 1
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:NV
Practice Address - Zip Code:89027-7503
Practice Address - Country:US
Practice Address - Phone:435-669-0075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NVDO3416207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program