Healthcare Provider Details

I. General information

NPI: 1972588572
Provider Name (Legal Business Name): DANIEL THOMAS COSGRO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DAN THOMAS COSGRO PAC

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 NE DOCTORS DR STE 6
BEND OR
97701-6092
US

IV. Provider business mailing address

PO BOX 5579
BEND OR
97708-5579
US

V. Phone/Fax

Practice location:
  • Phone: 541-706-6915
  • Fax: 541-706-6733
Mailing address:
  • Phone: 541-706-6915
  • Fax: 541-706-2991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00492
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: