Provider Demographics
NPI:1497284012
Name:KOSS, SHANE MICHAEL
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:MICHAEL
Last Name:KOSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17640 RACCOON CT
Mailing Address - Street 2:
Mailing Address - City:MORGAN HILL
Mailing Address - State:CA
Mailing Address - Zip Code:95037-6314
Mailing Address - Country:US
Mailing Address - Phone:408-656-5669
Mailing Address - Fax:
Practice Address - Street 1:2001 THE ALAMEDA
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-1136
Practice Address - Country:US
Practice Address - Phone:408-261-7777
Practice Address - Fax:408-259-2273
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator