Provider Demographics
NPI:1356980205
Name:WALLIS, SEAN (NP)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:WALLIS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:SEAN
Other - Middle Name:M
Other - Last Name:PIPPITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8769 W CORNELL AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80227-4820
Mailing Address - Country:US
Mailing Address - Phone:720-325-4228
Mailing Address - Fax:
Practice Address - Street 1:4747 ARAPAHOE AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1131
Practice Address - Country:US
Practice Address - Phone:303-415-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-24
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0995133-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner