Provider Demographics
NPI:1558251207
Name:KOGER, SHEA MARIE
Entity type:Individual
Prefix:
First Name:SHEA
Middle Name:MARIE
Last Name:KOGER
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 1:630 S 6TH ST E
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-2811
Mailing Address - Country:US
Mailing Address - Phone:425-324-0081
Mailing Address - Fax:
Practice Address - Street 1:32 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-4494
Practice Address - Country:US
Practice Address - Phone:406-243-0211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-05
Last Update Date:2025-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT207RS0010X207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine