MEDICARE: MRS. YVONNE HEREDIA-KOSTER ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1992731103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. YVONNE HEREDIA-KOSTER ATC

Provider Business Mailing Address
First Line	:	6724 DESERT CANYON DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-7604
Country	:	US
Telephone Number	:	915-845-3152
Fax Number	:

Provider Business Practice Location Address
First Line	:	2900 PERSHING DR
Second Line	:	SUITE B
City	:	EL PASO
State	:	TX
Zip	:	79903-2403
Country	:	US
Telephone Number	:	915-562-8525
Fax Number	:	915-566-3889

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	07/08/2007

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