Healthcare Provider Details

I. General information

NPI: 1689122129
Provider Name (Legal Business Name): SEAN T DOUGLAS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2016
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 DALTON AVE
PITTSFIELD MA
01201-2903
US

IV. Provider business mailing address

360 US HIGHWAY 1 BYP UNIT 102
PORTSMOUTH NH
03801-7105
US

V. Phone/Fax

Practice location:
  • Phone: 413-242-6577
  • Fax:
Mailing address:
  • Phone: 603-410-6700
  • Fax: 603-319-8308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number019994-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA5886
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: