Provider Demographics
NPI:1851706154
Name:MCDONOUGH, SEAN
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:MCDONOUGH
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 1:4262 JANET AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:SUITE 1008, CVT SURGICAL CENTER
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4537
Practice Address - Country:US
Practice Address - Phone:225-766-0416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-25
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200711363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical