MEDICARE: SEAN KOULABOUD APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	APRN-53-76899	KS
2	363LF0000X	Family Nurse Practitioner	53-76899	KS
3	363LF0000X	Family Nurse Practitioner	95004148	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	APRN-53-76899	OTHER	KS	KANSAS NURSING LICENSE
2	95004148	OTHER	CA	CALIFORNIA NURSING LICENSE

General Provider Information

NPI Number	:	1568837276
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SEAN KOULABOUD APRN

Provider Business Mailing Address
First Line	:	1600 CREEKSIDE DR STE 2100
Second Line	:
City	:	FOLSOM
State	:	CA
Zip	:	95630-3447
Country	:	US
Telephone Number	:	169-832-6639
Fax Number	:	169-830-6029

Provider Business Practice Location Address
First Line	:	1600 CREEKSIDE DR STE 2100
Second Line	:
City	:	FOLSOM
State	:	CA
Zip	:	95630-3447
Country	:	US
Telephone Number	:	169-832-6639
Fax Number	:	169-830-6029

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/07/2015
Last Update Date	:	05/03/2018

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Directions to “ SEAN KOULABOUD APRN” Practice Location

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