Healthcare Provider Details

I. General information

NPI: 1194267575
Provider Name (Legal Business Name): SETH LIGHT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2016
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 LAUREL ST STE A
DES MOINES IA
50314-3045
US

IV. Provider business mailing address

450 LAUREL ST STE A
DES MOINES IA
50314-3045
US

V. Phone/Fax

Practice location:
  • Phone: 515-247-8400
  • Fax:
Mailing address:
  • Phone: 515-247-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number127680
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number077999
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: