=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134217375
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEAN M DEGNAN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 165 HWY 50 SUITE 100
-----------------------------------------------------
City | STATELINE
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-588-3300
-----------------------------------------------------
Fax | 775-588-3353
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5757
-----------------------------------------------------
City | STATELINE
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89449-5757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-588-3300
-----------------------------------------------------
Fax | 775-588-3353
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 5488
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------