Provider Demographics
NPI:1134175615
Name:FOOSE, KEIKO MARIE (CNM)
Entity type:Individual
Prefix:MS
First Name:KEIKO
Middle Name:MARIE
Last Name:FOOSE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 61ST AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-7989
Mailing Address - Country:US
Mailing Address - Phone:970-336-1500
Mailing Address - Fax:970-336-1505
Practice Address - Street 1:1715 61ST AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-7989
Practice Address - Country:US
Practice Address - Phone:970-336-1500
Practice Address - Fax:970-336-1505
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO93588367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO62452037Medicaid
CO346953YLB8Medicare PIN
Q02512Medicare UPIN
516398Medicare ID - Type Unspecified