Provider Demographics
NPI:1619057791
Name:PROLAGO, SEAN-CARLO (PA)
Entity Type:Individual
Prefix:
First Name:SEAN-CARLO
Middle Name:
Last Name:PROLAGO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4722 W KELLOGG DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67209-2508
Mailing Address - Country:US
Mailing Address - Phone:316-440-2565
Mailing Address - Fax:316-440-2750
Practice Address - Street 1:4722 W KELLOGG DR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67209-2508
Practice Address - Country:US
Practice Address - Phone:316-440-2565
Practice Address - Fax:316-440-2750
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00662363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSP11258Medicare UPIN
KS042654Medicare ID - Type Unspecified