Provider Demographics
NPI:1083686117
Name:STROUP, SEAN PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:PATRICK
Last Name:STROUP
Suffix:
Gender:M
Credentials:MD
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:
Mailing Address - Fax:619-532-7202
Practice Address - Street 1:510 N 2ND ST STE 103
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6081
Practice Address - Country:US
Practice Address - Phone:208-381-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81753208800000X
IDM-15955208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA81753OtherSTATE
PAMD448962OtherSTATE