Healthcare Provider Details

I. General information

NPI: 1083390736
Provider Name (Legal Business Name): MEGAN KRISTINE ACOSTA O'GARA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2023
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4722 EAGLERIDGE CIR
PUEBLO CO
81008-2344
US

IV. Provider business mailing address

4722 EAGLERIDGE CIR
PUEBLO CO
81008-2344
US

V. Phone/Fax

Practice location:
  • Phone: 719-595-7563
  • Fax:
Mailing address:
  • Phone: 719-595-7563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0009026
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: