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NPI Code Detail

MEDICARE: MR. SEAN CRESTON SOARE PA-C

MEDICARE: MR. SEAN CRESTON SOARE PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant7396-23WI
2363A00000XPhysician Assistant085002227IL

General Provider Information

NPI Number : 1548242738
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. SEAN CRESTON SOARE PA-C
Provider Business Mailing Address
First Line : 29624 NETWORK PL
Second Line :
City : CHICAGO
State : IL
Zip : 60673-1296
Country : US
Telephone Number : 608-756-6278
Fax Number :
Provider Business Practice Location Address
First Line : 8201 E RIVERSIDE BLVD
Second Line :
City : ROCKFORD
State : IL
Zip : 61114-2300
Country : US
Telephone Number : 815-971-7000
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/15/2005
Last Update Date : 06/25/2025

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