Basic Information
| Provider Information | |||||||||
| NPI: | 1689122129 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUGLAS | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | PITTSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012014109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134472403 | ||||||||
| FaxNumber: | 4134472833 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | PITTSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012014109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134472403 | ||||||||
| FaxNumber: | 4134472833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2016 | ||||||||
| LastUpdateDate: | 01/13/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA5886 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 019994-1 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.