Provider Demographics
NPI:1336375047
Name:SPROUSE, TINA EUN (MD)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:EUN
Last Name:SPROUSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:EUN
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3949 BROWNING PL
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-6536
Mailing Address - Country:US
Mailing Address - Phone:919-787-7411
Mailing Address - Fax:919-789-4461
Practice Address - Street 1:3949 BROWNING PL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6536
Practice Address - Country:US
Practice Address - Phone:919-787-7411
Practice Address - Fax:919-789-4461
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD0423442085R0202X
NC2018-009022085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology