Provider Demographics
NPI:1720095672
Name:EGAN, COLLEEN DIANE (FNP, BC)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:DIANE
Last Name:EGAN
Suffix:
Gender:F
Credentials:FNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 DEAN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:LAVINA
Mailing Address - State:MT
Mailing Address - Zip Code:59046-7219
Mailing Address - Country:US
Mailing Address - Phone:406-575-4241
Mailing Address - Fax:775-890-5613
Practice Address - Street 1:522 DEAN CREEK RD
Practice Address - Street 2:
Practice Address - City:LAVINA
Practice Address - State:MT
Practice Address - Zip Code:59046-7219
Practice Address - Country:US
Practice Address - Phone:406-575-4241
Practice Address - Fax:775-890-5613
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK835363LF0000X
MT24181363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000911Medicaid
OR025349007OtherBSOR
AKP35479Medicare UPIN
OR025349007OtherBSOR
ORP35479001Medicare PIN
OR500029523Medicare PIN