Provider Demographics
NPI:1487195814
Name:O'BOYLE, SEAN
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:O'BOYLE
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 1:49 JESSE HILL JR DR SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-3049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11551 NUCKOLS RD STE F
Practice Address - Street 2:
Practice Address - City:GLEN ALLEN
Practice Address - State:VA
Practice Address - Zip Code:23059-5565
Practice Address - Country:US
Practice Address - Phone:804-364-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-18
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101268660208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101268660OtherVIRGINIA MEDICAL LICENSE