Healthcare Provider Details

I. General information

NPI: 1457519829
Provider Name (Legal Business Name): SEAN ROBERT CUSHING PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10123 SE MARKET ST
PORTLAND OR
97216-2532
US

IV. Provider business mailing address

5806 NE 23RD AVE
PORTLAND OR
97211-2710
US

V. Phone/Fax

Practice location:
  • Phone: 503-251-6168
  • Fax:
Mailing address:
  • Phone: 971-235-5913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 19589
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 153108
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: