Provider Demographics
NPI:1245338094
Name:BROGAN, KEVIN ANDREW (MPT ATC)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:ANDREW
Last Name:BROGAN
Suffix:
Gender:M
Credentials:MPT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 SHAW AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-3841
Mailing Address - Country:US
Mailing Address - Phone:559-299-2244
Mailing Address - Fax:559-299-2487
Practice Address - Street 1:145 SHAW AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612-3841
Practice Address - Country:US
Practice Address - Phone:559-299-2244
Practice Address - Fax:559-299-2487
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23807225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0PT238070Medicare ID - Type Unspecified