=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235649138
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEEGAN SHEA COSSIO LAT, ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2017
-----------------------------------------------------
Last Update Date | 06/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3220 N RESERVE ST
-----------------------------------------------------
City | MISSOULA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59808-1556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-396-7532
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9000 E NICHOLS AVE STE 104
-----------------------------------------------------
City | CENTENNIAL
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80112-3429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-396-7532
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | ATR-LAT-LIC-1881
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------