Provider Demographics
NPI:1073840278
Name:PAGE, SEAN W (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SEAN
Middle Name:W
Last Name:PAGE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-706-2663
Mailing Address - Fax:
Practice Address - Street 1:600 N ROBBINS RD STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4564
Practice Address - Country:US
Practice Address - Phone:208-706-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-826363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant