Basic Information
| Provider Information | |||||||||
| NPI: | 1619362001 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | LUKE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEINBERG | ||||||||
| OtherFirstName: | SEAN | ||||||||
| OtherMiddleName: | LUKE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10180 SE SUNNYSIDE RD OFC | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970158970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038132000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10180 SE SUNNYSIDE RD OFC EGS | ||||||||
| Address2: | |||||||||
| City: | CLACKAMAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970158970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038132000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2015 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD61103323 | WA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 63579 | MN | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | MD47700 | IA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 73695-20 | WI | N | Allopathic & Osteopathic Physicians | Surgery | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208600000X | MD201352 | OR | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.