Healthcare Provider Details

I. General information

NPI: 1902339617
Provider Name (Legal Business Name): SHANNON KEAGON YEAGER BOCP, C.PED.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2017
Last Update Date: 04/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2470 PATTERSON RD STE 9
GRAND JUNCTION CO
81505-1028
US

IV. Provider business mailing address

2470 PATTERSON RD STE 9
GRAND JUNCTION CO
81505-1028
US

V. Phone/Fax

Practice location:
  • Phone: 970-243-6000
  • Fax:
Mailing address:
  • Phone: 970-243-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224L00000X
TaxonomyPedorthist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: