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General NPI Number Information
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NPI Number | 1073596136
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Entity Type | Individual
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Provider Name | SEAN R WEATHERSTON P.T.
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Gender | Male
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Dates
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Enumeration Date | 11/22/2005
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Last Update Date | 12/04/2007
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Provider Practice Location Address
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Address Line | 211 E LOGAN ST SUITE 101
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City | CALDWELL
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State | ID
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Zip | 83605-4835
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Country | US
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Telephone | 208-454-9839
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Fax | 208-454-0727
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Provider Business Mailing Address
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Address Line | 2101 W GROUSE ST
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City | NAMPA
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State | ID
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Zip | 83651-8353
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Country | US
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Telephone | 208-465-8087
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Fax | 208-454-0727
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 1523
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License Number State | ID
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