Provider Demographics
NPI:1891310892
Name:COOK, SEAN E
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:E
Last Name:COOK
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 1:1743 N WINDSOR PARK CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:ID
Mailing Address - Zip Code:83644-5672
Mailing Address - Country:US
Mailing Address - Phone:208-965-3517
Mailing Address - Fax:
Practice Address - Street 1:211 E LOGAN ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4882
Practice Address - Country:US
Practice Address - Phone:208-963-1871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID64857363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology