Provider Demographics
NPI:1265400899
Name:SCULLY, SEAN GREGORY
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:GREGORY
Last Name:SCULLY
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 1:1245 KUALA ST
Mailing Address - Street 2:
Mailing Address - City:PEARL CITY
Mailing Address - State:HI
Mailing Address - Zip Code:96782-3900
Mailing Address - Country:US
Mailing Address - Phone:808-784-2273
Mailing Address - Fax:
Practice Address - Street 1:91-590 FARRINGTON HIGHWAY #300
Practice Address - Street 2:
Practice Address - City:EWA
Practice Address - State:HI
Practice Address - Zip Code:96707
Practice Address - Country:US
Practice Address - Phone:808-674-0269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2565363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily