Healthcare Provider Details

I. General information

NPI: 1740624691
Provider Name (Legal Business Name): SEAN M STEVENS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 06/09/2025
Certification Date: 06/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4300 MARKET PTE DR STE 100
BLOOMINGTON MN
55435-5435
US

IV. Provider business mailing address

500 N RAINBOW BLVD STE. 203
LAS VEGAS NV
89107-1082
US

V. Phone/Fax

Practice location:
  • Phone: 952-767-4574
  • Fax:
Mailing address:
  • Phone: 208-867-2102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDO2113
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number283605
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number79610
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: