Provider Demographics
NPI:1528678851
Name:MOON, SEAN
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:MOON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 SE 4TH ST
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:99324-1317
Mailing Address - Country:US
Mailing Address - Phone:509-386-7474
Mailing Address - Fax:
Practice Address - Street 1:626 SE 4TH ST
Practice Address - Street 2:
Practice Address - City:COLLEGE PLACE
Practice Address - State:WA
Practice Address - Zip Code:99324-1317
Practice Address - Country:US
Practice Address - Phone:509-386-7474
Practice Address - Fax:509-386-7474
Is Sole Proprietor?:No
Enumeration Date:2020-08-02
Last Update Date:2025-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP70039106363LP0808X
WARN61058757163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health