Provider Demographics
NPI:1932251535
Name:PROCTOR, SEAN JASON (PT)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:JASON
Last Name:PROCTOR
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 PINK DOGWOOD LANE
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322
Mailing Address - Country:US
Mailing Address - Phone:912-748-2160
Mailing Address - Fax:
Practice Address - Street 1:310 EISENHOWER DR
Practice Address - Street 2:SUITE 7
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-2632
Practice Address - Country:US
Practice Address - Phone:912-303-0487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007329225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBCVWMedicare ID - Type Unspecified