Healthcare Provider Details

I. General information

NPI: 1073596136
Provider Name (Legal Business Name): SEAN R WEATHERSTON P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E LOGAN ST SUITE 101
CALDWELL ID
83605-4835
US

IV. Provider business mailing address

2101 W GROUSE ST
NAMPA ID
83651-8353
US

V. Phone/Fax

Practice location:
  • Phone: 208-454-9839
  • Fax: 208-454-0727
Mailing address:
  • Phone: 208-465-8087
  • Fax: 208-454-0727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1523
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: