Healthcare Provider Details

I. General information

NPI: 1831594134
Provider Name (Legal Business Name): SEAN MICHAEL CALNAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2014
Last Update Date: 10/15/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 MOUNT AUBURN STREET MGB INTEGRATED CARE
WATERTOWN MA
02472
US

IV. Provider business mailing address

11 MOUNT AUBURN ST
WATERTOWN MA
02472-3981
US

V. Phone/Fax

Practice location:
  • Phone: 781-653-0100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number#PA 00788
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA5181
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberPA5181
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: