Basic Information
| Provider Information | |||||||||
| NPI: | 1336375047 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPROUSE | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | EUN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEE | ||||||||
| OtherFirstName: | TINA | ||||||||
| OtherMiddleName: | EUN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3949 BROWNING PL | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276096536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197877411 | ||||||||
| FaxNumber: | 9197894461 | ||||||||
| Practice Location | |||||||||
| Address1: | 3949 BROWNING PL | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276096536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197877411 | ||||||||
| FaxNumber: | 9197894461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2009 | ||||||||
| LastUpdateDate: | 04/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD042344 | DC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 2018-00902 | NC | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.