Healthcare Provider Details

I. General information

NPI: 1417488131
Provider Name (Legal Business Name): SEAN CRAIG STOUT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N CURTIS RD STE 100
BOISE ID
83706-1339
US

IV. Provider business mailing address

901 N CURTIS RD STE 100
BOISE ID
83706-1339
US

V. Phone/Fax

Practice location:
  • Phone: 208-378-0080
  • Fax:
Mailing address:
  • Phone: 208-378-0080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2017021058
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number2020009905
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberM-16211
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: