Provider Demographics
NPI:1083390736
Name:ACOSTA O'GARA, MEGAN KRISTINE
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:KRISTINE
Last Name:ACOSTA O'GARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4722 EAGLERIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2344
Mailing Address - Country:US
Mailing Address - Phone:719-595-7563
Mailing Address - Fax:
Practice Address - Street 1:4722 EAGLERIDGE CIR
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2344
Practice Address - Country:US
Practice Address - Phone:719-595-7563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-27
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
COPA.0009026363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program