Provider Demographics
NPI:1972588572
Name:COSGRO, DANIEL THOMAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:THOMAS
Last Name:COSGRO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:DAN
Other - Middle Name:THOMAS
Other - Last Name:COSGRO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 5579
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-5579
Mailing Address - Country:US
Mailing Address - Phone:541-706-6915
Mailing Address - Fax:541-706-2991
Practice Address - Street 1:2275 NE DOCTORS DR STE 6
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6092
Practice Address - Country:US
Practice Address - Phone:541-706-6915
Practice Address - Fax:541-706-6733
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
ORPA00492363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR00492OtherPROFESSIONAL LICENSE NUMBER