Healthcare Provider Details

I. General information

NPI: 1225225485
Provider Name (Legal Business Name): SEAN DOMINIC CRESAP C.P.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 10/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 N CHELAN AVE A-5
WENATCHEE WA
98801-6622
US

IV. Provider business mailing address

630 N CHELAN AVE A-5
WENATCHEE WA
98801-6622
US

V. Phone/Fax

Practice location:
  • Phone: 509-663-2490
  • Fax: 509-663-2147
Mailing address:
  • Phone: 509-663-2490
  • Fax: 509-663-2147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberPS00000162
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: