Healthcare Provider Details

I. General information

NPI: 1689207391
Provider Name (Legal Business Name): MARK JASON COBB CRNP - AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2020
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S 3RD ST
GADSDEN AL
35901-5304
US

IV. Provider business mailing address

PO BOX 136
OHATCHEE AL
36271-0136
US

V. Phone/Fax

Practice location:
  • Phone: 256-282-6082
  • Fax:
Mailing address:
  • Phone: 256-282-6082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-116446
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1-116446
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number1-116446
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number1-116446
License Number StateAL
# 5
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number1-116446
License Number StateAL
# 6
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1-116446
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: