Healthcare Provider Details

I. General information

NPI: 1447606231
Provider Name (Legal Business Name): SEAN JOSEPH PRENDERGAST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2016
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N SANTIAM HWY
LEBANON OR
97355-4363
US

IV. Provider business mailing address

PO BOX 1193
CORVALLIS OR
97339-1193
US

V. Phone/Fax

Practice location:
  • Phone: 541-258-2101
  • Fax: 541-451-7862
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD193346
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: