Provider Demographics
NPI:1780312751
Name:WOLVEN, SEAN DEAGON
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:DEAGON
Last Name:WOLVEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9880 W FLAMINGO RD STE 260
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-8085
Mailing Address - Country:US
Mailing Address - Phone:702-680-0016
Mailing Address - Fax:
Practice Address - Street 1:9880 W FLAMINGO RD STE 260
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-8085
Practice Address - Country:US
Practice Address - Phone:702-680-0016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-09
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4940225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist