Provider Demographics
NPI:1669961868
Name:DUGAN, SEAN (LAC)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:DUGAN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4777 N WATERFRONT WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-2772
Mailing Address - Country:US
Mailing Address - Phone:208-953-7690
Mailing Address - Fax:208-953-7690
Practice Address - Street 1:6540 W EMERALD ST STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8782
Practice Address - Country:US
Practice Address - Phone:208-953-7690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA105171100000X
IDACU354171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty